Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104224500 THIS BOOK 15 THE GIFT OF CORNELL UNIVERSITY LIBRARY 924 104 224 500 .r- W s'Cft, <, 5> 'A ^:> o^ -i^.-^. <5 C^v ^>K'^%. ^iVi ^^^.^/^ '5- 'o. o ^ '■ PATHOLOGY AND TREATMENT VEISTEREAL DISEASES. THE PATHOLOGY AND TREATMENT YENEEEAL DISEASES; HfCLUDING THE RESULTS OF RECENT INVESTIGATIONS UPON THE SUBJECT. BT FEEEMAN J. BUMSTBAD, M.D., PROFESSOR OF VENEREAL DISEASES AT THE COLLEGE OF FnYSlCIANS A>*I) SURUEONS, NEW YORE; SFRGEOS TO CHARITY HOSPITAL,; LATE SFRGEOH TO THE HEW YORK EYE AND EAR INFIRMARY, ETC, ETC. THIRD EDITION, EBVISBD AND ENLARGED, WITH ILLUSTRATIONS. PHILADELPHIA: H E IT E T O.LEA. 1870. <^o f B ^^ Mo, 5375" Entered according to Act of Congress, in the year 1870, by HENRY C. LEA, in the" Office of the Librarian of Congress. All rights reserved. ^ ^ PHILADELPHIA; OOLLIXTSf PKINTES* PREFACE TO THE THIRD EDITION. The present edition is, I believe, what its title asserts it to be, " revised and enlarged." The whole work has undergone a thorough revision, and many changes and additions have been made, the chief of which are the following : — In Part First the subject of the treatment of stricture has been rewritten, and due importance has been given to the operations of rupture and internal urethrotomy. Parts Second and Third, relating to the chancroid and to syphilis, have been remodelled, and in a great measure rewritten. The sub- ject of visceral syphilis, especially, which was almost unknown at the time of the publication of the first edition, has received the attention which more recent investigations require. . The chapter on Syphilitic Affections of the Eyes has been revised and brought up to the present level of ophthalmic knowledge by one whom I regard as unexcelled and rarely equalled in his Spe- cialty, Dr. E. Gr. Loring, Surgeon to the Manhattan Eye and Ear Infirmary. The text of previous editions has been compressed, and portions omitted, especially when relating to subjects now fully established and no longer controversial ; yet the size of the present volume is increased' by sixty-four "pages. My intention has been, as heretofore, to supply a practical trea- tise which should meet the wants of the busy practitioner, and present the subject of venereal diseases as held by the best autho- rities of the present day. In carrying out this view I have freely (V) VI PEEFACE. availed myself of the works of others, and I desire especially to acknowledge my indebtedness to Lancereaux, whose admirable work on syphilis is so rich in pathology, and to Fournier, Tvho excels as ah able and conscientious observer.. Upon no subject more than venereal diseases is assistance to be derived from an appeal to the eye by means of plates. It was the intention of the publisher and of myself to introduce colored illus- trations into the present edition, and considerable labor and ex- pense were devoted to this purpose, which was, however, finally abandoned in view of the increased cost, of the volume which it was found its execution would necessitate. Moreover, the want: referred to is already supplied by the republication of OuUerier's Atlas of Venereal Diseases, which fully illustrates the various topics treated of in the following pages. I desire to thank most heartily the medical profession for the favor with which previous editions of this work have been received, . and I can only trust that in its present shape it may be thought worthy of a continuance of the same. F. J. BUMSTBAD 16 West 32d St., New York, October, 1870. PREFACE TO THE FIRST EDITION. The object in the preparation of this work has been to furnish the student with a full and comprehensive treatise upon Venereal Diseases, and the practitioner with a plain and practical guide to their treatment. In carrying out this design, theoretical discussions have been made subordinate to practical details ; and, in the belief that the success of treatment depends quite as much upon the manner of its execution as upon the general principles upon which it is based, no minutiae, calculated to assist the surgeon or benefit the patient, have been regarded as unworthy of notice. The additions to our knowledge of Yenereal, during the last ten years, have been numerous, and in the highest degree important. Among the most remarkable may be mentioned the distinct nature of the chancroid and syphilis ; the innocuousness of the secretion of the chancre when applied to the person bearing it, or to any indi- vidual affected with the syphilitic diathesis ; the removal of certain obstacles to a general belief in the contagiousness of secondary lesions; the fact that syphilis pursues the same course whether derived from a primary or secondary symptom, commencing, in either case, with a chancre at the point where the virus enters the •system ; the definite period of incubation of the true chancre, and of general manifestations ; the inef&cacy of the abortive treatment of syphilis ; and the phenomena of " syphilizatiou," improperly so- called, and their correct interpretation. Several of these topics are entirely new within the period mentioned, and upon others much clearer views have been obtained ; so that our present knowledge pf Venereal Diseases may be- regarded as far more complete and satisfactory than at any previous time. As yet, however, these results and the investigations which have led to them are, for the most part, scattered through the pages of medical periodical litera- ture, in our own and foreign languages.- . To collect them into one volume, and thus render them more accessible to the American reader, has also entered into the purpose of the author. New York, July, 1861. (Vii) CONTENTS, PAGE InTEODITCTION »os. .•••.'•.. 17 PART I. GONOREH(EA AND ITS COMPLICATIONS. CHAPTER I. — Uhbtheal Gokokkhcea ih the Male 51 Preliminary considerations 51 Symptoms 53 Causes and nature of gonorrhoea 58 Treatment ............ 63 Abortive treatment 64 Treatment of the acute stage 69 Treatment of the stage of decline 73 Copaiba and cubebs 80 Obstacles to success 88 Treatment of special symptoms 90 CHAPTER II.— Gleet 93 Symptoms 94 Pathology _ 95 Treatment . ^ gg Applications by means of the endoscope 100 Injections _ J02 Deep urethral injections 104 Blisters _ jQg Separation of tlie affected surfaces ^ 108 CHAPTER III.— Balanitis 109 (Raises .... 109 Symptoms jjq Treatment hq CHAPTER IV.— Phimosis II3 Symptoms • 1J4 Treatment j-^g Circumcision jjir ( viii ) CONTENTS, ix FACE CHAPTER v.— Pakaphimosis 121 124 125 CHAPTER VI.— Swelled Testicle . . . . . Causes . , Seat ...,,.. 127 Symptoms 130 Pathological anatomy I37 Treatment . I39 CHAPTER VII. — Inflammation op Cowper's Glands 146 CHAPTER VIII. — Inflammation of the Prostate 147 Acute prostatitis , . . . . 147 Diagnosis 149 Treatment I49 Chronic prostatitis 150 • Treatment , 152 CHAPTER IX. — Inflammation of the Bladder 155 Treatment 157 CHAPTER X. — GrONORRHCEA IN Women . . ' 159 Causes 1^59 Symptoms . ^ 162 Gonorrhoea of the vulva 163 Gonorrhoea of the vagina 166 Gonorrhoea of the urethra 169 Complications 171 Diagnosis 172 Treatment 173 CHAPTER XI.— GoKORKHCEAL Ophthalmia 182 Frequency 183 Causes 184 Symptoms 186 Diagnosis 189 Treatment 190 CHAPTER XII. — GoNOBRHCEAL RnEUMATrsM 199 Causes . . • 201 Seat 203 Symptoms 205 Diagnosis 209 Nature 210 Treatment *...... 212 CHAPTER XIII.— Vegetations 215 Treatment 217 X CONTENTS. PAGE CHAPTER XIV.— Stkictoee op the UKEiHKi 219 Anatomical consideratious 219 Transitory strictures 235 Permanent or organic strictures 237 Seat 240 Number . . . . • 243 Form 243 . Degree of contraction 244 Pathology of stricture 247 Abscess and fistula 2-19 Lesions of the bladder 250 Lesions of the ureters and kidneys 252 Lesions of the genital organs 252 Constitutional effects of stricture 253 Symptoms of stricture 254 Causes of stricture 259 Diagnosis of stricture 263 Exploration of the urethra 264 Introduction of the catheter 271 Treatment 275 Constitutional means " . . 275 Dilatation 276 Continuous dilatation 279 " Over distention" 280 Internal incision and rupture 281 Caustics 293 External perineal urethrotomy 294 Consequences of operations upon stricture 300 Treatment of retention of urine 302 Puncture by the rectum 308 Opening of the urethra 311 Puncture above the pubes 311 Puncture through the symphysis 312 Treatment of extravasation of urine 312 Treatment of urinary abscess and fistula 313 Proposed set of urethral instruments 314 PART II. The Chancroid and its Complications. CHAPTER I.— The Ceanokoid . ' 316 Virus 316 Contagion of 321 Frequency 324 Seat 325 Chancroid from inoculation 329 CONTENTS, :^1 PAGE Chancroid from contagion . ■ . . . , ' . „ , . 332 Development 332 Period of progress 333 Stationary period 335 Reparative stage ... 336 Number 337 Condition of neighboring ganglia ........ 838 Varieties 339 Diagnosis 339 Prognosis 344 Treatment 344 Choice of a caustic 34G Local applications 349 CHAPTER II. — PEcniiAEiTiES dependent ok the Seat of Chancroids . . 353 Chancroids upon the integument of the penis 353 Chancroids of the fraenum 353 Suh-prepntial chancroids 355 Urethral chancroids- 356 Chancroids of the female genital organs ...... 357 Chronic chancroid of prostitutes 360 Chancroids of the anus and rectum 362 Venereal stricture of the rectum 363 CHAPTER III. — The Chanceoid complicated with Excessive Inflam- mation AND WITH Phagedena . 365 Inflammatory or gangrenous chancroid 365 Phagedenic chancroids 367 Serpiginous chancroid 368 Sloughing phagedenic chancroid 369 Treatment of phagedsena 370 CHAPTER IV. — The Chanckoid complicated with Syphilis. — "Mixed Chancre" '374 CHAPTER v.— Buboes. 379 Simple inflammatory bubo 380 Indolent bubo 382 Virulent bubo 383 Treatment 388 General treatment 389 Counter-irritants 390 Compression 391 Methods of opening 391 Treatment of difficult cases 395 CHAPTER VI.— Lymphitis 398 XU CONTENTS. PART III. Syphilis. PAGE CHAPTER I.— Ihtkoduotory Remarks ....... 401 Syphilitic virus . . . . , 401 Syphilis commonly occurs but once in the same person . . . 402 Exceptions to this law 403 Syphilis possesses a period of incubation 405 The order of evolution of syphilitic symptoms and the classification founded thereon 406 CHAPTER II.— The Initial Lesion op Syphilis, oe Chanoke . . . 414 Period of incabation 416 ' Symptoms 418 Diagnosis 429 Special indications from the seat of chancres . ^ . . . 432 > Urethral chancres. 432 Chancres about the mouth 432 Chancres in women ......... 433 Treatment 434 CHAPTER III. — Inddeation of the Ganglia and op the Lymphatics . . 438 Induration of the ganglia. (Syphilitic bubo. ) . . . . . 438 Constancy 438 Seat 440 Time of appearance 441 Symptoms * . , . 442 Course and termination ......... 442 Diagnosis 444 Induration of the lymphatics , . 44.5 Treatment of induration of the ganglia and lymphatics .... 446 CHAPTER IV. — GrBNEHAL SYPHILIS. — lN.TRODgCTOEY Remaeks ... 447 General syphilis always. follows a chancre . . . . . . 447 Period of incubation 44s Some of the symptoms of general syphilis are contagious ... - 453 What general symptoms are oontagjous ?,..... 468 Syphilis pursues essentially tlie same course^ whether derlve^d fr»m a primary or secondary symptom ; in the latter case, as in the former, the initial lesion is a chancre 472 CHAPTER v.— Peogkosis OP Syphilis , . 478 CHAPTER VL— Treatment of Sypbilis. . .', 484 Hygiene and tonics 485 Mercurials 488 Fumigation . . ; 493 Inunction 49g CONTENTS. Xiii PASB Hypodermic injection 497 Salivation- ^09 Duration of treatment • • = . . . . . 503 Iodine and its compounds gng Vegetable decootious and infusions 514 Nitric acid , gj^g CHAPTER VII.— Teeatment op Syphilis by Repeated Inoculation . . 516 CHAPTER VIII.— Syphilitic Fever ; State op the Blood ; Engoksement op THE Lymphatic Gakolia ; Icterus 533 Syphilitic fever g33 State of the blood g3g Engorgenjent of the cervical ganglia 535 Icterus 537 CHAPTER IX. — Syphilitic Affections op the Skin 538 Changes in the sensibility of the skin 63y Syphilitic erythema ' 542 Syphilitic papules 544 Syphilitic squamse 546 Syphilitic vesicles 547 Syphilitic buUse 548 Pemphigus 548 Eupia 549 Syphilitic pustules 551 Acne 651 Impetigo 552 Ecthyma 552 Syphilitic tubercles 555 Ulcers 558 Treatment 559 CHAPTER X. — Syphilitic Affections OP THE Appendages OF THE Skw . 562 Alopecia 562 Onychia 564 CHAPTER XL— Mucous Patches 566 Treatment 572 CHAPTER XII. — Affections op the Subcutaneous Cellular Tissue. Gummy Tumors. Affections of the Mammary Glands 573 Diffuse form 573 Circumscribed form, or gummy tumors 573 Affections of the mammary glands 575 CHAPTER XIII. — General Remarks upon Syphilitic Affections op Mucous Membranes 576 Erythema 4 . 576 Ulcers 577 XIV CONTENTS. PA0E CHAPTER XIV. — Syphilitic Afpectioks of the Digestive Oksaits . . 579 Bnooal cavity •. . . 579 Erythema 579 Mucous patches and ulcers 579 Treatment 580 Psoriasis of the mouth 583 Tubercles of the tongue 583 Necrosis of the maxillary bones 585 Gummy tumor of the soft palate 587 Pharynx 589 (Esophagus 589 Stomach and intestines 591 Pancreas 593 Liver 593 Syphilitic interstitial hepatitis ........ 594 ~ Gummy hepatitis 594 Fatty and amyloid degeneration 595 Certain blood-forming glands 597 Spleen 597 Thyroid body 597 Deep lymphatic glands 597 Syphilitic cachexia . 598 CHAPTER XV. — Syphilitic Affections of the Oesaks of Respikatioh . 599 Nose 59& Larynx, trachea, and bronchia ........ 601 Syphilitic aphonia 601 Syphilitic laryngitis 602 Ulceration of the trachea ........ 604 Lungs 607 Interstitial pneumonia 607 Gummy tumors 607 CHAPTER XVI. — Syphilitic Appections of the Heart akd Bloodvessels . 609 Heart 609 Bloodvessels 610 CHAPTER XVII. — Late Syphilitic Affections op the Genito-Ueikabt Organs 611 Syphilitic orchitis 611 Symptoms 612 Pathological anatomy 614 Diagnosis 615 Treatment 616 Affections of the vasa deferentia,the vesiculse seminales and the prostate 617 Affections of the penis 618 Affections of the ovaries, Fallopian tubes, uterus, and vagina . . 619 Affections of the kidneys . . . 619 Diffused form 620 Gummy tumors g21 Cicatrices ........... g21 CONTENTS. XV PAGE CHAPTER XVIII.-^Syphilixio Affections op the Nekvohs System . . 622 Tlie brain 622 Meningitis ... ^ ...... . 623 Gummy tumors 623 Convulsions 624 Hemiplegia 628 General paralysis 629 Insanity 629 The spine 630 Paraplegia 631 The nerves . 631 Motor nerves of the eye 632 Facial nerve . . . . 633 Fifth nerve 633 Spinal nerves 633 Splstnohnio nerves 635 CHAPTER XIX. — Syphilitic Affeotiohs of the Muscles and theik Acobsso- EiES AND Syphilitic Panaris 636 Affections of the muscles . . ■ 636 Diffuse form. Muscular contraction ...... 636 Muscular tumors 638 Affections of the tendons 640 Syphilitic panaris c*. . . . 640 CHAPTER XX. — ^^S.YPHiLiTic Affections of the Bones, the Cartilages, and THE Joints 642 Affections of the bones 642 Inflammatory form. Osteoperiostitis 643 Exostosis 644 Gummy form. -Osteomyelitis 645 Dry caries 648 Cicatrices 649 Treatment 650 Affections of the cartilages 651 Affections of the joints 652 Syphilitic synovitis 652 Syphilitic articular ostitis . 652 CHAPTER XXI. — Syphilitic Affections OF THE Eyes 654 Affections of the bones of the orbit ^ . 654 Affections of the lachrymal passages . . - 655 Affections of the eyelids 657 Affections of the conjunctiva 658 Affections of the cornea 659 Iritis 660 Simple or plastic iritis 661 Serous iritis 662 Parenchymatous iritis 663 Infantile iritis '.671 XVI CONTENTS. FAQE Choroiditis 672 Plastic choroiditis . . . , 672 Serous choroiditis 673 • Parenchymatous choroiditis 674 Retinitis 675 CHAPTER XXn. — Syphilitic Affectioks of thb Eab 678 External ear 678 Tympanal membrane 678 Middle and internal ear 680 CHAPTER XXni.— Congenital Syphilis 681 Etiology 681 Transmissibility 683 Abortion 685 Period of development 686 Symptoms 689^ General aspect of syphilitic infants 689 Coryza 690 . Affections of the skin and mucous membranes .... 690 Onychia 692 Affection of the thymus gland 692 Changes in the lungs 692 . Changes in the liver 693 Peritonitis 695 Affections of the periosteum and bones 695 Hydrocephalus . 696 Affections of the supra-renal capsules and pancreas . . . 696 Prognosis 696 Treatmeut 697 VEISTEREAL DISEASES. INTEODUOTION. There are three diseases, which, from their origin in sexual intercourse, have been denominated Venereal, viz : Goistoeehcea ; THE Contagious Uloer of the Genitals, or Chancboid ; ■ and Syphilis. These three affections, for a long time confounded, have been, since the beginning of the present century, gradually resuming the relations which they held to each other nearly four hundred years ago. The medical mind has been travelling in a circle, and having completed the round, is now where it stood in the last part of the fifteenth and the first of the sixteenth century. The distinction between the above-named diseases which is now admitted — certainly by a very considerable number of our profes- sion, unsurpassed in intelligence, learning, and experience, and including names which have long been acknowledged as the highest authority — was fully recognized for twenty or thirty years after Columbus discovered the new world. The earlier history of venereal diseases has recently been very thoroughly investigated, especially by Bassereau,' Langlebert,^ Gha- balier,' and Eollet,* and the conclusions attained, startling as they may in some respects appear, are yet supported by such an amount of proof drawn from the original sources, as to give them every ' Aflfeotions de la Peau Symptomatiques de la Syphilis, Paris, 1852, ' Rgoherdhes Historiques sur la Doctrine Moderne des Maladies Vfineriennes, I'Union M6d. 1855. ' Preuves Historiques de la Plurality des Affections dites V6n6riennes, ThSse de Paris, 1860 (No. 52). I am indebted to M. Chabalier's very able thesis for many of the following facts relating to the history of venereal diseases, « Reoherches sur la Syphilis, etc., Paris, 1861. 2 ir 18 INTBODUCTIOIir. appearance of truth ; at all events, they have not been disproved, although Bassereau's -work has been for many years before the pro- fession. I propose as briefly and concisely as possible to state what is at present known upon this subject, i, EAELT HISTORY OF GONOEEHCEA. Gonorrhoea has existed among all nations, and from the earliest times of -which we have any record. It is clearly referred to by Moses in the 15th chapter of Leviticus, where he kys down rules for the goTernment of those who are affected with " a running issue out of the flesh." Among the Greeks and Eomans, gonorrhoea appears to have been less common than among the Hebrews ; still, unquestionable traces of it are found. Hippocrates describes five kinds of leucorrhcea, in addition to discharges dependent upon inflammation of the womb, which are mentioned separately. Herodotus states that "the Scythians made an irruption into Palestine and pillaged the temple of Yenus Urania. The togi-y Goddess sent upon them and their posterity the woman's disease, which is characterized by a running from the penis. Those attacked by it are looked upon as accursed." ' Oelsus'' was also acquainted with balanitis and gonorrhoea; the lat- ter dependent, as he supposed, upon an ulcer within the urethra; and Cicero says that "incontinence gives rise to dysuria, in the, same manner that high living causes diarrhoea." At subsequent periods, this disease, and, in many instances, its complications of .swelled testicle and cystitis, were described with more or less detail by Mesne' in 904; by Halli Abbas,* one of the Persian magi, who followed the doctrines of Zoroaster and wrote in 980 ; by Ehazis,^ a , learned Arabian physician, born in Chorosana in 852 ; by Albucasa,' another Arabian of the eleventh century ; by Cons^antine of Oartha^ge;' by Michael Scott' in 1214; by Gariopon- tus of Salerno ; by Eogerius, John Gaddesden' of England (com- mencement of fourteenth century); John de Concoregio," John 1 Clio, lib. I. * De MedioinS,, book vi., chap. 18. » Summ. III., part 4, sect. i. * De Virgsa Passioulbua, Causia eorum et Signis, book ix., chap. 28. ' Rhazis, book X., chap. 3. ' Theoric. neo non Practic, tract, xxi., fol. 92 et 93. I ConstantiBUS Afrioanus. De Morborum Cognitione et Curatione, lib. v. ' Michael Scott, De Procreat. Horn. Physion., Cap. vi. > John Gaddesden. Kosa Anglica, Practica Medieinse, a Capite ad Pedes, lib, ii., c. ■svii.; fol. 107. " Practica nova Medieinse. Lucidur, tract, iv., fol. 66. INTRODUCTION. 19 Arculanus, Guy de Chauliac/ Yalescus de Tarento, Jolm Ardern,'' settled at London in 1371 ; tod by many others. Since the close of the fifteenth century, -when the study of venereal diseases received new impulse from the irruption of syphilis into Europe, it is hardly necessary to state that every medical writer has been familiar with the existence of gonorrhoea. EAELT HISTORY OF THE CONTAGIOUS ULCER OF THE GENITALS. The history of the contagious ulcer of the genitals is essentially the same. Ulcers of the genital organs and suppurating buboes are described by nearly all the Grreek, Latin, and Arabian writers on medicine. Hippocrates gives very minute directions for the treat- ment of abscesses in the groin, dependent upon ulcerations of the womb and of the genitals. Oelsus is still more explicit, and clearly describes the simple, phagedenic, serpiginous, and gangrenous vene- real ulcers, which are recognized at the present day. It would be difScult, for instance, to draw up a more faithful description of the phagedenic chancroid than the following: "Ulcus latius atque altius Nouvelles Doctrines sur la Syphilis, p. 100. 36 INTEODUCTION. contract an ulcer, wliicli -would be foUo-wed by a train of general symptoms, extending over a period of years, and perhaips affecting his offspring. This remarkable difference was explained on the ground of a diversity in the constitutions of the two individuals. The seed was supposed to be the same in both cases, but some pecu- liarity of soil in wliich it was implanted produced a different mode of germinaticfa. Therfe was an unknown something in the system of Mr. A. which- protected him from constitutional infection, while the absence of the same in Mr. B. exposed him to it. If either of these men should communicate his disease to a woman, her sore, it was thought, would be attended by systemic syphilis or not, according to her peculiar idiosyncrasy, and independently of the source from which the virus came. The unsatisfactory nature of these views had attracted attention and awakened doubts of their correctness in the minds of several surgeons. Hunter devotes Part YII. of his work on Venereal to a consideration of "Diseases resembling the Lues Venerea, which have been mistaken for it," and which he is often evidently at a loss to c]assify. But although frequent misgivings as to the correctness of his views are to be found in his writings, he still maintained that " there is no difference in the kind of matter, and no variation can arise in the disease from the matters being of different degrees of •strength ; the variations of the symptoms in different persons de- pend upon the constitution and habit of the patient at- the time."* Abernethy was also at a loss to account for many syphilitic phe- nomena, and especially for the development or non-development of general syphilis after . venereal ulcers which closely resemble each other. In his work entitled ^' Surgical Diseases resembling Syphilis," when speaking of venereal ulcers, he says : " It is from their effects upon. the constitution alone that we can judge whether they are syphilitic or not." (p. 59.) Oarmichael," in 1814, took a decided stand in favor of a plurality of poisons, of which he admitted four, but he believed that they were all capable of affecting the constitution, though some were susceptible of spontaneous cure without mercury. The distinctions which he drew were grounded more. upon the character of the erup- tion than upon the appearances of the ulcer. These views were never generally adopted, even in Dublin, where ' RicoRD and Huntek on Venereal, 2d edition, p. 47. ' Essay on the Venereal Diseases which have heen confounded with Syphilis. INTRODUCTION. 37 Carmicliael resided, and after a brief notoriety -were almost entirely forgotten. But Eicord appears to have liad tlie clearest anticipations of the discovery which was destined to emanate from his " school," or from among his pupils and followers. In the absence of proof to the con- trary, this surgeon advocated, in general, the unity of the syphilitic virus, and explained its different effects on the ground of constitu- tional differences already referred to ; but Mr. Victor de M6ric' states that Eicord remarked to him many years ago: "You may rest assured that some day distinct origins will be found for the infecting and non-infecting chancres ;" and in the first edition of his Letters on Syphilis, published in 1851 (p. 257), when referring to the fact that in experiments upon syphilization, inoculation. of the matter of chancroids had always produced chancroids, while in the single instance that pus from a true chancre had been employed, a true chancre was the result, this author says: "If these results were constantly obtained, we should be forced to conclude, that there are differences in syphilis which do not depend alone upon the condition of the individual upon whom the cause acts, but upon differences in the cause itself." "With this brief history of opinion regarding this important ques- tion, we come down to the year 1852, when the first successful assault was made on the old doctrine of idiosyncrasies and temperaments, and led to its final overthrow and the establishment of the duality of the chanorous virus. At this time, M. Bassereau, a former pupil of Eicord, published his "Traite des Affections de la Peau, Sympto- matiques de la Syphilis," a work characterized throughout by great originality of thought and accuracy of investigation. Although nominally a treatise upon syphilitic eruptions alone, many other subjects connected with syphilis are discussed, and among them the unity or duality of the virus, hitherto regarded as one. Justice to the author, the intrinsic and historical interest of his remarks, the manly and cogent style of his reasoning, and the absence, so far as I am aware, in the English language, of any suitable exposition of his views expressed at this early day, demand a somewhat extended quotation, which I shall give in the form of a free translation, with such abridgment as my limits as to space require. It is necessary to premise that this question is discussed by M. Bassereau in his chapter on syphilitic erythema, which, being one of the earliest symptoms of general syphilis, affords a better ' Lettsomian Lectures, 1858, p. 9. 38 INTEODUCTIOlir. opportunity, for tracing tlie connection between primary and secondary lesions than any other. The cases of erythema, to which frequent reference is made, number 170, if we exclude twenty-eight in which tlie absence of information regarding the primary ulcer precluded any comparison. In the tenth section of the chapter upon this subject, entitled: " Eecherche des causes qui ont pu determiner le developpement de I'eryth^me, c'est-a-dire la generalization des symptSmes syphilitiques dans I'economie," M. Bassereau says : — " There can be no question of the fact that there are venereal ulcers which may be treated by the most simple remedies without- the employment of any mercury whatsoever, and yet never be followed, by the symptoms of general .syphilis. Any one may convince himself of this truth by inquiring of old men, many of whom will' state that they had venereal ulcers several times in their youth, which were treated with simple cerate, lint, or other means destitute of specific action, and though they have never taken mercurials, there has not been the slightest appearance of constitu- tional syphilis during the thirty or forty years which have since elapsed. Many persons also will repeatedly have ulcers and escape infection, but will finally contract another which will be followed by a syphilitic eruption. "Why this difference ? "What should limit the action of the sore in the one case and in the other extend it to the whole system? This is an interesting problem, and I will proceed to give the results of my attempts to solve it. Let no one who is wont to pay respect to opinions which have received the stamp of authority take umbrage at the novelty of the propositions ■vrhich I am about to present, or be hasty in rejecting them. The question at issue is so important that it deserves serious examination. It is not to be decided by an appeal to the vague impressions left on the mind by former experience, or by the doctrines of this school or that ; it can only be settled by new investigations undertaken for the very purpose. I ask therefore of unbiassed men to devote the necessary time to verify the facts which I am about to present; and to give them their most scrupulous attention. "Among the causes which I have investigated, I have endeavored to ascertain if age has any influence upon the infection of the system by syphilis, and I have satisfied myself that it has none. From birth to the most advanced years, men may have Sores which, at any age, may be followed by general syphilis ; and though infec- tion is more common among the young, it is simply because they are more exposed. Sex is equally devoid of influence. Eicord INTRODUCTION. S9 states that venereal ulcers are less frequently indurated in women than in men, -which is equivalent to saying that women are less liable to syphilis, since it can be easily shown that infection attends in most cases indurated chancres. I do hot believe, however, that Eicord carries the induction thus far. For my own part, I think that the rarity of induration in women is only apparent. Indeed, in an examination of the same number of venereal ulcers in the two sexes, I have found nearly the same proportion indurated in. the one as in the other ; with this difference, that the induration was generally poorly marked on the vulva, while it was very decided upon the penis. Just 9,s the skin of various parts of the body ia not equally susceptible of the development of induration, so this symptom is less frequent upon the genital organs in women than in men. But women are not on this account less exposed to syphilis Though fewer persons of this sex are affected with this disease, it is because the number who are addicted to debauch is incomparablj^- less than of men ; whence venereal affections of all kinds, syphilis included, are less common among them, and the difference cannot be attributed merely to sex. "Again, idiosyncrasy will not explain the fact that a sore is only local in its effect in one person, while in another the system at large is contaminated. This is proved by the number of persons who, after having numerous simple ulcers, contract another which becomes indurated and is followed by general manifestations. " Can such different results from two acts of contagion by a virus reputed the same be accounted for by the changes which frequently take place in the constitution, and by virtue of which a man is not affected in the same manner by the same agent at times very nearly approximated ? Doubtless such dissimilar effects might depend upon the particular disposition existing at the time of contagion ; but this expla,nation is admissible only in default of a better, espe- cially as it is opposed to what we know of the action of specific causes, which always tend to produce the same results. "I have carefully studied the temperament and constitution of persons affected with syphilitic erythema, in order to discover if any one of these organic modifications of the system might not influence the development of syphilis, but such inquiry has led to no positive result. I have found all temperaments affected in nearly equal proportion ; none can therefore be regarded as peculiarly con- ducive to the extension of the virus throughout the economy ; and the same may be said of difference of constitution. " An insufficient amount or the bad quality of food, which is a 40 INTRODUCTION. po-werful aggravating cause of syphilitic symptoms, has been so rarely observed in the cases of erythema which have come under my notice, that it is impossible to ascribe to it the development of general syphilis. The abuse of alcoholic stimulants, changes of temperature, and intercurrent diseases appear to have had no more effect. I have'merely noticed that chancres contracted during warm weather are more rapidly followed by syphilis. than during cold. " The above remarks clearly show that neither age, sex, idiosyn- crasy, temperament, constitution, hygienic influences, nor coexisting diseases which might be supposed to have depressed the system at the time contagion took place, can, each by iJ;self, be regarded as the determining cause of infection ; and if we group them all together instead of considering each singly, my statistics will show that they will not account for one-third of the cases of constitutional disease. The better to appreciate the etiological value of these influences) T have examined the condition of those persons whose ulcers, in spite of the absence of all treatment capable of retarding or destroying a tendency to secondary symptoms, have not been followed by gene- ral syphilis. I have compared one hundred such cases with an equal number of patients affected with syphilitic erjrthema, and have found in each nearly the same proportion of lymphatic tem- peraments, feeble constitutions, bad hygienic influences, etc., thus confirming my opinion of the necessity of searching for other than physiological and hygienic causes of the generalization of syphilitic manifestations. " I have also sought for the solution of this question in the sore 'itself. I have endeavored to ascertain if repeated acts of contagion might not favor the appearance of secondary symptoms. On exam- ination of the cases cited, I found that in 112 cases the eruption appeared after several successive ulcerations, and in 86 after a single one. Notwithstanding the predominance of the former, it cannot, 1 think, be admitted that repeated attacks are the cause of constitu- tional infection. The idea that the action of a virus must be accu- mulated to produce its utmost effect is but little in accordance with the medical knowledge we already possess. In a number of my cases, also, there was so long an interval between the ulcers that it appears to me difficult to attribute to the first contagion any influ- ence whatever in the production df the syphilitic manifestations which followed the last exposure. "Again, I have inquired if individuals affected with sfeveral ulcers at one time, were not more exposed to constitutional infec- tion than those having only one, and who consequently bore upon INTRODUCTION. 41 iheir persons a smaller surface secreting contagious watter; but I found this could not be tbe case, for of ttie 170 instances of syphi- litic erythema, 141 had had but one, and only 29 multiple ulcers ; whence I conclude that neither the plurality of the sores nor the extent of the seicreting surface can be regarded as the cause of the constitutional manifestations which sometimes appear. These results are analogous to those obtained by Kirkpatrick, Dimsdale, and Gatti in experiments with the virus of variola, from which it ap pears that there is no connection between the number of inoculated points and the copiousness of the consecutive eruption. Girot even observed that the eruption of variola was milder and more discrete after inoculating in six places than when only two punctures were made. "An analysis of these cases of syphilitic erythema also shows that the development of general syphilis is not affected by the situa- tion,* degree of ulceration, or duration of the sores. General symp- toms may supervene, on whatever part of the body the sore is situated ; and the intensity of the former is not increased when the ulcer is at a distance from the' genital organs, as was once supposed by Boerhaave. A decided tendency to extend by ulceration is also innocent of the development of constitutional syphilis ; for I have often seen the mildest and most superficial erosions followed by infection, while phagedenic sores proved innocuous. Those iilcers which last for a long period are not more likely to terminate in secondary syphilis than those which cicatrize within a moderate or short space of time, as may also be seen from an examination of these 170 cases. " On the other hand, induration is so frequent a symptom of these ulcers" that it is impossible not to admit that it bears an intimate relation to the syphilitic erythema which ensued. But even if it could be shown that all chancres are indurated, must we necessarily say that induration is the cause of infection? By no means; for this would only be avoiding the question instead of solving it, since the cause of the induration would still remain to be discovered. " Finally, in my investigations I have endeavored to ascertain if any relation existed between the symptoms presented by my patients and those of the persons from whom they contracted their disease. Such inquiry is often dif&cult, for men are frequently infected by 1 At the time this was written, the fact that chancroids are rarely met With upon the head or face was not known. 2 Of the 170 chancres, 157 were known to he indurated; in 13 induration was doubtful. 42 INTRODUCTION. women wlioin tliey never see but once, and of whose name and address they are ignorant. Some have intercourse with several ■women within a short time preceding the appearance of the sore, so that the source of the virus is doubtful ; others refuse to give any information with regard to the persons with whom they have had connection. In some cases, however, we are able to compare the symptoms in the two sexes. Patients often bring to me for examination the women who infected them, or else put me in the way of visiting them at their homes. Frequently, also, at the H6pital des Yeneriens, I have found two or three, or even a larger number of men who contracted their disease from the same woman, either on the same day or at a few days' interval. Finally, in several instances I have seen both a wife and a husband, and even their children, all affected with syphilis which had been introduced into the family through one of its members. " These repeated confrontations of persons infected by each other — undertaken at first to determine what syphilitic lesions are con- tagious and what are not; to show what symptoms may succeed others, and what modifications the same symptom may undergo by transmission between individuals of different sex and temperament — have led to the discovery of that hitherto mysterious cause by virtue of which venereal ulcers sometimes limit their action to the part on which they are situated and the neighboring ganglia, and at other times extend their effect to the system at large and are followed by general syphilis. The following propositions embody the results obtained from the confrontation of patients affected not only with erythema, but also with other syphilitic eruptions and primary sores, with those persons from whom their, disease was derived : — "If we compare persons who have had venereal ulcers followed by general symptoms with those persons who inoculated them, or with those whom they in turn have inoculated, we find that all, without exception, have had constitutional syphilis ; never, in anv case, has the action of the sore been merely local. " On the other hand, by the comparison of individuals who have had ulcerations which did not result in general manifestations with the individuals who infected them, or with those whom they have infected, we find without exception that the. latter, equally with the former, have had sores, the action of which was limited to the part first inoculated. Thus an -ulcer followed by constitutional syphilis never gives rise to a merely local ulcer ; and a purely local ulcer cannot produce an ulcer which wiU be followed by the general manifestations of syphilis. The uniformity of the facts which have INTEODUCTIOir. 43 come under my observation — none but apparent exceptions having ever been met with— fully justifies me in enunciating the following proposition as a law: — • "Whenever a person has a chamre and afterwards general syphilis, the generalization of the disease is first of all due to the fact that the person from whom the contagion cam^ had a chancre which was neces- sarily followed by general symptoms. "Of thirty-four cases of syphilitic erythema, in which I have been able to confront the patients with those who infected them, and in some instances with those whom they had afterwards infected, in thirty-one, conformably to the law just enunciated, all the indi- viduals thus confronted presented lesions of the same character; all without exception had ulcers which were followed by general syphilis. In only three, from the absence of symptoms of general infection, did there seem to be any exception, but induration was found at the site of the sore, showing that the exception was only apparent ; moreover, the mercury which had been administered for the latter fully accounted for the absence, or delay in the appearance, of general manifestations." Bassereau's observations included only cases of venereal ulcers followed by general symptoms, or, in other words, only cases of true syphilis ; but other observers soon applied the same piode of investigation to the local contagious ulcer of the genital organs, and found the same law obtained, this sore being also transmitted in its kind from one generation to another. In 1856, M. Dron' was able to collect one hundred and eleven instances of confrontation, including those of Bassereau relating to the initial lesion of syphilis, those of M. Clerc relating to the chan- croid, and others relating to both varieties furnished by Diday, Eollet, Eodet, and Fournier, and in all, without exception, the type of the ulcer remained unchanged in passing, from one individual to another. Further investigations, under the supervision of Eicord, and with the same result, were made by MM. Fournier and Gaby, who availed themselves of the unequalled facilities for such exa- mination afforded by the chief venereal hospitals of Paris — one (du Midi) devoted to men, the other (St. Lazare) to women — and of the vigilance of the French police. These observations were pub- lished in detail by M. Fournier in his edition of Eicord's Leqons sur h. Chancre^ and also in a pamphlet entitled, i^^c^ercte sur la Con- tagion du Chancre,^ and comprise fifty-nine cases of transmission of, 1 "Du Double Virus Sypliilitique," Thfese de Paris, 1856. 2 Paris, 1858. = Paris, 1857. 44 INTRODUCTION. chancres, and thirty-nine of chancroids. The value of many of these cases was materially enhanced by the fact that two or more men were contaminated by the same woman, and thus the testi- mony in favor of the duality of the chancrous virus was multiplied. In one, two friends, who shared the favors of the same woman having a true chancre, caught, each of them, a chancre followed by general symptoms ; and the father of one of them, an old man aged seventy -three, had connection with his son's mistress, and met with the same fate. Again, six persons were infected from the same source, and the consequences in all were identical, viz., chancres and general, manifestations. So with the chancroid ; in several of Fournier's cases, two, three, or four men, bearing chancroids, were found together in the wards of the H6pital du Midi, all of whom ascribed their contagion to the same woman; she, on examination, was proved to have the same species of sore ; and in none did gene- ral symptoms appear during several months that they were kept under observation. Again, upon no other ground than a duality of poisons, can we satisfactorily explain ^hj the same individual should repeatedly contract a local sore, and after a short interval incur another con- tagion resulting in constitutional infection ; or why a chancroid and a true chancre should-ever coexist upon the same person — in- stances of which are of almost daily occurrence. Nearly every surgeon has the opportunity to satisfy himself of the truth of this doctrine by personal observation ; let him but take note of the not unfrequent cases in which a husband gives a venereal ulcer to a wife whose fidelity cannot be called in question, and he will find that they will both escape, or both incur constitutional infection. Thus, every one can contribute his quota to the statistics on this interesting subject. For myself, in a somewhat extended field of, observation during eighteen years of practice, I have never seen an instance of interchange of the chancroid and syphilis. It is upon this evidence, viz., the results of clinical experience and the immutability of the characteristics of the "hard" and "soft" sores in successive! generations, that the modern belief in the duality of the chancrous virus is founded. It should be remem- bered, however, that the "characteristics" referred to do not con- sist in the hardness and softness of the sores themselves but in their constitutional character on the one hand, and their local cha- racter on the other. Hardness and softness are, indeed, usually: present in the two kinds of sore, but they are not essential features; and it is no argument against the doctrine of duality to show that INTRODUCTIOIf. 45 in such and sucTi a case a man had upon his penis a sore with a perfectly soft base, which was followed by an outbreak of general syphilis, unless it can also be shown that this sore was derived from a local sore, a chancroid, in the woman with whom he had connection. The remembrance of this fact would have saved much fruitless discussion. But it remains to speak of another view of this subject, advo- cated, by M. Clerc. Two years after the publication of M. Basse- reau's work, this gentleman issued a pamphlet,' in which, while admitting the perpetuity of the two kinds of sore in successive generations, he yet maintained that the . soft chancre was a deriva- tive of the hard, being the result of the transmission of the syphi- litic virus through the system of a person who had already been contaminated by syphilis. He believed that the soft chancre bore the same relation to the hard that varioloid does to variola, and the false to the true vaccine pustule, and, in accordance with this view, he applied the name of "chancroid," which has since been retained, to the former, and reserved the term chancre exclusively for the latter. A chancroid onpe formed, he did not deny the possibility, of its reverting to its original type, viz., a true chancre ; but he declared he had never witnessed such an occurrence, and maintained that, as a general rule at least, it never recovered its original power of in- fecting the constitution, but continued to be a local ulcer without constitutional reaction. Thus, practically, M. Clerc may be said to be as much of a "dualist" as Bassereau, although theoretically he is a "unitist," since he believes in a common origin of the two species of venereal ulcers. With regard to the history of the two affections, M. Clerc denies that the allusions of ancient writers to ulcerations of the genital organs had any reference to the chancroid, but rather to sores of simple origin ; he believes in the modern appearance of syphilis in Europe about the year 1494, and that its supposed derivative, the chancroid, was first known about 1520. I am not aware that these views of M. Clerc received the support of any authority besides himself. They were generally looked upon as visionary and entirely unsupported by evidence. Syphi- lographers continued to be divided into the two classes of "unitists" and " dualists ;" the former recognizing no distinction between the ■ Mgmoire du Chancr'oide Syphilitiqne, Paris, 1854. I 46 INTRODUCTION. simple and syphilitic ulcers ; the latter regarding them as totally and radically distinct. It is well known to the readers of the previous editions of this work, and of my translation of CuUerier's Prkis Icomgra^fhique, that I have been a stanch advocate of Bassereau's views ; and that I have not admitted even the most remote connection between the chancroid and true syphilis. I am not now prepared to say that I have been mistaken in this matter ; but truth compels me to lay before my readers certain facts, verified within the last few years, which, to say the least, render M. Clerc's views less improbable than they at first appeared. I repeat, and I wish the remark to.be specially noted, that I am not ready to say that these facts establish M. Clerc's theory, though I confess they add much to its support. The question must still be regarded sub j'udice. A short time can- not fail fully to decide it, and until then it is better to suspend judgment. Above all, in whichever way it may be decided, let it be noticed that the distinction between the chancroid and the true chancre will continue to be as important as ever; and that the rules of practice, which I have always advocated in the present work, will remain unchanged. I will now proceed ip state what these facts are. In the first place, Mr. Henry Lee, of London, Prof. Boeck, of Christiania, and others, have succeeded in certain instances by means of stimulating the sore with powdered savine, etc., in inocu- lating the secretion of true chancres upon the persons bearing them. The success of the inoculations has been apparent on the second or third day, by the evolution of a pustule, covering an ulcer with sharply cut edges, and furnishing a secretion which was re-inoculahle. upon the same and other persons. Absence of incubation ; development as a pustule; the familiar aspect of the underlying ulcer ; above all, the capability of re-inoculation ; all this looks very much like what we are in the habit of calling a chancroid ! But the experimentum crucis still remains to be tried. Is the sore thus produced some- times, if not always, local in its character ? May it, like the chan- croid, be transferred to persons entirely free from specific taint, without contaminating them with the syphilitic virus ? This question is a difficult one to decide, since the necessary con- ditions for its solution are, for obvious reasons, rarely to be met with. It naturally arose at the time that M. Clerc first advanced his theory, and was decided in the negative from seven cases which were said to have been observed b/ CuUerier,^ Melchior Epbert,* * FoDENiEE, Contagion dn Chancre, p. 57. ' Dkon, Thfese, already referred to. INTRODUCTION. 47 Diday/ Fournier, and Gaby. In all these cases it was asserted that the syphilitic virus, after inoculation upon persons already infected with syphilis, still preserved its attribute of contaminating the con- stitution, when further transmitted, to sound individuals. More recent observations would seem to prove that this is far from being invariably the case. Thus, as I shall have occasion to show when speaking of syphi- lization, so called, there is no reason to believe that any absorption takes place from the sores resulting from the successful auto-inocu- lation of the secretion of true chancres, but, on the contrary, that the ulcers are entirely local. But still more satisfactory evidence- is to be found in the follow- ing cases observed by Dr. Gjor, of Christiania, who has kindly given me the details in writing: — Case 1 — In practising syphilization Dr. Gjor had succeeded in auto- inoculating the secretion of mucous patches, and was Continuing a series of reinoculations with the virus from this source upon the patients whom he was subjecting to this process. Oetavia EUingsen, aged 25, a public girl, who was an inmate of the ward for some simple disease, and who had always been frqp from syphilitic taint, inoculated herself in Septem- ber, 1864, without the consent of Dr. G., with some of this matter, which she stealthily procured from one of the other patients. The inoculations succeeded in producing pustules, but from that time to the present she has never presented any symptoms of general syphilis. Case 2 — August 6, 1865, Kirstine Andrine Henricksdatter, aged 19, free from all taint of syphilis, inoculated herself in a similar manner with matter originating in the successful auto-inoculation of mucous tubercles. The inoculations succeeded, but she was kept under obser- vation until January 1, 1866, without showing the least sign of general syphilis. In the summer of 1867, she contracted a true chancre in sexual intercourse, which was followed by the usual train of secondary symptoms. Case 3 — Ida Schultz, 18 years old, also inoculated herself with suc- cess with the same matter about the same time, and up to the present date has exhibited no symptoms of constitutional infection. Thus in three instances matter which was undoubtedly originally . syphilitic, after inoculation upon individuals already infected with syphilis, produced only local sores without constitutional reaction when transferred to sound persons; in other words, the syphilitic was apparently transformed into the chancroidal virus. It is true that these cases are few in number, but they are worthy of the most ' Aiinuaire de la Syphilis, annSe 18'58, p. 277. 48 INTRODUCTIOIT. attentive consideration. The further practice of syphilization can hardly fail to call forth other cases which shall either corroborate them or the contrary. Until then, as I have already remarked, it is better to suspend our final judgment. The term "chancroid," as applied to the local ulcer, has been quite generally adopted without reference to the truth or falsity of M. Clerc's views. It is a convenient name, and one that I think should be retained. The term "chancre" may then be applied exclusively to the initial lesion of syphilis. Unfortunately the German school of to-day, represented by Hebra, Zeissl,' Reder,^ and Lihdwurm,^ who believe in the radical distinction between the •two diseases, have applied the term chancre to what we call the "chancroid," and designate our "chancre" as the "initial lesion of syphilis," or "primary syphilis." This interchange of terms should be borne in mind in reading modern German works upon Venereal. In connection with this subject I have only to add that Fournier has also investigated a number of cases by confrontation in order to ascertain whether a tendency to phagedsena was transmitted from one generation to another. He found that it was not, and that in the great majority of instances phagedenic ulcers were derived from sores which exhibited no such tendency whatever. Its origin is probably complex, being attributable in some cases to noxious principles in the primary pus of contagion, more frequently to con- stitutional cachexia in the recipient, and sometimes to both causes combined ; but without entering fully into its etiology, it is suffi- cient for our present purpose to say that the virus of phagedenic ulcers is not a distinct species, since this form of ulcer shows no tendency whatever to perpetuate itself from one generation to another. COMPAEISOK OF THE THEEE POISONS OF GONOEEH(EA, THE CHANCROID, AND SYPHILIS. A comparison of the three poisons of gonorrhoea, the chancroid, and syphilis, so far as we are at present able to understand their nature, leads to the following conclusions. ' Allgemeine Wiener Medizinische Zeitung, January, 1862. A translation of a portion of this article may be found in the Boston Medical and Surgical Journal, May 15, 1862. Zeissl's clinique is made up of Hebra'a venereal patients, and the views of the former surgeon are fully endorsed by the latter. . 2 Ueber die Trennung des Schankers von der Syphilis. Medizinische Jahrbiicher Heft I., 1862. ' Ueber die Yerschiedenheit der syphilitischen Krankheiten. • INTEOUUCTION. i\) The only property common to them all is their communication, for the most part, by contact of the genital organs. The poisons of gonorrhoea and of the chancroid are alike in that their action is limited and never extends to the general system ; nor does one attack afford the slightest protection against a second. They differ in that the poison of gonorrhoea may arise spontane- ously, while that of the chancroid, so far as we know, never thus originates ; that gonorrhoea chiefly affects the surface — true iilcera- tion being rarely induced — and, in its complications, most frequently attacks parts connected with the original seat of the disease by a continuous mucous surface, as the prostate, bladder, and testicle; while the chancroid, on the contrary, is an ulcer, involving the whole thickness of the integument or mucous membrane, and its complications are seated in the absorbent vessels and ganglia. It would also appear that the poisons of these two affections are limited to one common vehicle, viz., pus. Van Roosbroeck, on the authority of RoUet, has proved by experiment that if the discharge of gonorrhoeal ophthalmia be deprived of its pus-globules by iiltra- tion, the remaining fluid is innocuous ; and EoUet states that he has obtained like results with the pus of chancroids. If these experi- ments can be relied on, they prove that the virus is not diffused throughout the purulent secretion, but is confined to the- pus-globules which it contains. This conclusion is sustained by the fact that neither the poison of gonorrhoea nor that of the chancroid pver reaches the general circulation, and it is well known that pus- globules are not capable of absorption. When the purulent niatter of a chancroid enters the absorbent vessels, as occurs in the forma- tion of a virulent bubo, it is arrested by the first chain of lymphatic ganglia, and goes no farther. The paint used in tattooing is some- times conveyed to a ganglion in a similar manner ; ' butneither in this case nor the former is there complete absorption.' The syphilitic virus is alone capable of infecting the system at 1 Virohow has given a beautiful plate of the deposit of pigment matter in the axillary gland of an arm, the skin of which had heen tattooed, and describes the process of absorption as follows: "A certain number of particles find their way into lymphatic vessels, are carried along in spite of their heaviness by the current of lymph, and reach the nearest lymphatic glands, where, they are separated by filtration. We never find that any particles are conveyed beyond the lymphatic glands and make their way to more distant points, or that they deposit themselves in any way in the parenchyma Of internal organs." {Cellular Pathology, English translation, p. 184.) » E,OLLET, De la Plurality des Maladies V^n^riennes, Gaz. M^d. de Lyon, No. 5, 1860. 4 50 INTRODUCTION. large, and of affording protection by its presence against subsequent attacks. Unlike the poisons of gonorrhoea and the chancroid, it is not limited to purulent matter, but exists in the blood, in the fluids of secondary lesions, in the semen, and probably in other secretions. The secretion of one form of chancre (the superficial variety), as shown by microscopical examination, is often entirely destitute of pus-globules ; " and the presence of the virus in secondary symptoms is proved by their power of contagion, and in the semen by the occurrence of hereditary syphilis in the offspring when the father is alone infected. There is no opposition whatever between these three poisons; they may all coexist in the same person, who may at the same time have gonorrhoea, a chancroid, and a chancre, or other syphilitic lesion ; hence we may explain a case related by Acton in which each of three students contracted one of these diseases froni inter- course with the same woman on the same day. Two of these poisons may be present in the same fluid, as when the secretion of a chancroid or chancre mingles with that of gonorrhoea ; or as in the " mixed chancre " resulting from inoculation of the same part, either at the same time or successively, by the virus of the chancroid and ■ that of syphilis. The secretion of a chancroid or of a syphilitic lesion may also mingle with the other animal poisons, as the vaccine virus, and each will produce its usiial effects unmodified by the pre- sence of the other. DIVISION OF THE PEESENT WORK. Following the natural order suggested by the above considera- tions, I propose to divide the present work into three parts: the First treating of Gonorrhoea and its Complications ; the Second of the Local Contagious Ulcer of the Genitals or Chancroid, and its 'Complications ; and the Third Syphilis. ' Mr. Henry Lee believes that a chancrei is always an ulcer affected with specific 'Bdhtesive inflammation, and, unless irritated, destitute of pas-glohules. Of 95 oases •«samined by the microscope at King's College Hospital, in none was (he secretion U>urulent. (Medico-Chir. Trans, vol. xlii. p. 450.) PART I. GONOERHCEA AND ITS COMPLICATIOI^S. CHAPTER I. URETHRAL GONORRHCBA IN THE MALE. Peeliminaey Considebations. — By far the most frequent dis- ease originating in sexual intercourse, is an affection of certain mucous membranes, a prorainent symptom of "wMoli is an increased secretion and discharge from the diseased surface. At various times and places, this disease has received different names, founded on the prevailing ideas of the nature of the secretion referred to. At an early period in the history of Venereal, the discharge was supposed to consist of the semen, and hence the disease was called gonorrhoea, from 7o»ri, sperm, and ^ec^ to flow ; a name which is still in use among American and English writers, notwithstanding the incorrectness of the supposition in which it originated.' The French call the same affection " blennorrhagie," or a flow of mucus, a name which is also erroneous, since the discharge does not consist of mucus alone, but of a mixture of mucus and pus. In popular language it is termed " clap'"' by the English, and " ohaude-pisse" by the French. The chief mucous membranes subject to gonorrhoea are those lining the genital organs in the two sexes, and the conjunctiva ■ ' CocKBORNE (The Symptoms, Naturp, Cause, and Cure of Gonorrhoea, London, 1757) first established the faut that gonorrhoea is not a flow of semen. . ' Clip, dap, clippe, to embrace, to fondle. "QJippe we ia covenant, and each of us clippe other." — Piers Ploughman. "HekissethherandeiiypefAherfuHoft."— CuAUCEu: T?ie Merchant's Tale. "Oh, let me clip ye in arms aa round as when I woo'd !"— Shakspeake: Oorlolanus. \ "The lusty vine, not jealous of the ivy. Because ste clips the elm !" — Beadmost and Fletohek. " Old French, clapises, public shops kept by prostitutes. Hohhjn ; — clapiers, an old term for houses of ill fame." [51 ] 52 UEETHRAL G0n6eEH(EA IN THE MALE. oculi. Gonorrhoea of the anus, moutli, nose, and external ear are, indeed,- mentioned by authors, but the existence of all of them ia more or less doubtfal. Perhaps there is the least question in ad- mitting gonorrhoea of the anus and rectum, though it is said to be rare even in countries where unnatural practices are frequent ; but we can hardly admit under' this head those cases in which the anus is simply excoriated by a discharge flowing from the urethra or vulya, without extension of the disease to the rectum. Eepoirted cases of gonorrhoea of the mouth, nose, and external ear are very few in number, and are all of them open to serious question ; as, for instance, the supposed case of gonorrhoea of the nose, reported by Mr." Edwaxds,' in which it is very doubtfiil whether the disease was of this origiii and not a simple catarrhal affection ; and from M. Diday's experiments" this membrane would seem to be exempt. Besides, when we recollect how frequently a disregard of cleanliness must cause the application of gonorrhceal matter to the nostrils and lips, and how readily such applications excite inflammation of the ocular conjunctiva, the great rarity of suspected cases of nasal and buccal gonorrhoea must convince us, without the necessity of such experiments as those above mentioned, that certain mucous mem- branes are more, apt to contract gonorrhoea than others ; and in this we may find an analogy to an extraordinary fact which at one time excited much attention, viz., that all parts of the body are not equally susceptible of the two species of venereal ulcers ; the chan- croid never being met with upon the head or face, although it may be implanted there by artificial inoculation. The reason of the preference of these diseases for certain localities escapes us, but they are not the only instances of the kind met with. The sjrmptoms and the treatment of gonorrhoea vary according as the disease affects the male or female, and according also to the portion of mucous membrane attacked ; it will be convenient, there- fore, to consider this affection under corresponding heads. UEETHRAL GONOERHCEA "Ilf THE MALE. Men are more liable to contract gonorrhoea than women ; and of a given number of cases of this disease in the former, in a large proportion it is the urethra which is affected. Cases of urethral discharge in the male outnumber all other forms of gonorrhoea in 1 London Lancet, Am. ed, June, 1857. ' Annuaire de la Syphilis, annfie 1858. SYMPTOMS. . 53 the t-wo sexes combined. The explanation of this fact will appear when we come to consider the causes and nature of gonorrhoea. Symptoms. — The symptoms of urethral gonorrhoea in the male first appear, as a general rule, between the second and fifth day ,after exposure ; though, in exceptional cases, as late as the seventh, tenth, or fourteenth day; but their occurrence after this time, as alleged by some authors, is, I believe, to be explained on the ground that the earliest manifestations of the disease have been overlooked. At first, the symptoms are very slight, consisting only of an uneasy or tickling sensation at the mouth of the canal, which, on examina- tion, is found more florid than natural, and moistened with a small quantity of colorless and viscid fluid, which glues the lips of the meatus together. This moisture of the canal gradually increases in amount, until on pressure a drop may be made to appear at the orifice ; at the same time it begins to lose its clear watery appear- ance, and assumes a milky hue. Examined under the microscope, it is found to consist of mucus with the addition of pus-globules ; the number of the latter being proportioned to the depth of color of the discharge. Meanwhile, some smarting is felt by the patient in the anterior portion of the canal during the passage of the urine. Such are the symptoms of the early stag6 of gonorrhoea. The exciting cause of the disease has been applied to that portion of the canal which lies near the orifice of the meatus and which was chiefly exposed to contagion, and the ensuing inflammation is gradually lighted up in this part, and has not yet extended beyond that por- tion of the urethra known as the fossa naviciilaris. This early stage of gonorrhoea is often called "the stage of incubation," a name which is objectionable because the inflammatory process is doubtless set up at the time of the application of the exciting cause. Time is required for it to produce i^s full effect, and the earlies'. symptoms are but slowly and gradually ushered in. A more appro- priate name is the first or preparatory stage. It is important to recollect the symptoms of this stage and the fact that the disease is as yet confined to the anterior portion of the urethra, since, as we shall see hereafter, a more rapid method of cure may now be re- sorted to than is admissible in the subsequent stages. The first stage of gonorrhoea usually lasts from two to four days. The symptoms gradually increase in intensity, until, in about a week after exposure, the second or inflammatory stage may be said to commence. If we examine the penis during this stage, we find the mucous membrane covering the glans reddened, and the whole 54 UBKTHEAL GONOEKH(EA IK THE MALE. extremity of the organ swollen so tliat the prepuce fits more tightly than natural. In some cases the latter is puffed out by oedema in the cellular tissue, and phimosis may exist, rendering it impossible to uncover the glans. The inflammatory blush is especially marked in the neighborhood of the meatus, the lips of which are swollen so as to contract the calibre of the orifice. The discharge has now become copious, so much so in some instances as to drop from the meatus as the patient stands before you. It is thick, of a yellowish cream color, and not nnfrequently tinged with green. This green- ish hue, as in the sputa of pneumonia, is due to the admixture of blood-corpuscles, which may be sufficiently numerous to produce the characteristic color of blood. The penis generally, and espe- cially upon the under surface over the course of the canal, is pain- ful and tender on pressure. "While passing his urine, the patient complains of intense pain which is now not confined to the anterior part of the canal, but is felt in all that portion of the organ anterior to the scrotum, or is even more deeply seated. The severity of the suffering during the act is in some instances very great. The pain is compared to the sensation of a hot iron introduced within the canal, and the popular name, chaude-pisse, given to the disease by the French, is fully justified. This pain is excited in part by the irritation produced upon an abnormally sensitive membrane by the salts contained in the urine, but chiefly, I am inclined to think, by the distention of the contracted and sensitive canal by the passage of the stream. Hence, during the act, the patient involuntarily relaxes the abdo- minal walls, holds his breath, and keeps the diaphragm elevated, in order to diminish the pressure upon the bladder and lessen the size and force of the stream of urine. In consequence also of the urethra being contracted and more or less obstructed by the dis- cbarge, the stream is forked or otherwise irregular. Another source of suffering in this stage of- gonorrhoea is the nocturnal erections, which are apt to come on after the patient is warm in bed. The genital organs are in a highly sensitive condi- tion, and are readily excited by lascivious dreams, the contact of the bedclothes, or a distended bladder ; or, independently of such Dxciting cause, they assume a state of erection which even in health is more apt to occur during sleep. When thus excited, it will oflien be found that the penis is bent in the form of an arc with its concavity downward. This condition is known as choi-dee. Its explanation is veiry simple. The urethra, the chief seat of the inflammation, runs along the under surface of the penis. Plastio SYMPTOMS. 55 lympH is effused around the canal, gluing the tissues together and rendering this portion of the penis less extensible than the remain- ing portion composed of the corpora cavernosa. Hence, in a state of erection, the corpus spongiosum surrounding the urethra, not being able to yield to the extension, acts like the string of a bow, and ohordee is produced. The stretching of the parts thus ad- hering 'together excites pain, -which is often very severe. The sufferer, awaking from sleep, instinctively grasps the penis in his hand, and bends it in a still smaller curve, so as to remove the strain from the under surface and thus ease the pain. I have been in the habit in myjectures of illustrating the mechanism of chordee by gluing a piece of tape along the surface of an india rubber condom, and then distending it with air or water. It not- uufre- quently happens that during one of these attacks of chordee, the mucous membrane of the urethra becomes lacerated, and hemor- rhage takes place from the canal. In this way nature may produce local depletion, and if the flow be not excessive, the effect is often beneficial. The above explanation of the mechanism of chordee is the one usually received, though it is proper to state that it is rejected by Mr. Milton> who believes that chordee is due to spasm of the mus- cular fibres, which KoUiker and Mr. Hancock have shown to exist around the whole course of the urethra.^ Milton's explanation is opposed by the fact that bending the penis so as to increase the curve of the arc affords partial ease to the pain of chordee, and I am not convinced that the generally received opinion should thus be laid aside, though it is highly probable that spasmodic muscular action plays some part in the production of the frequent erection* and chordee which take place in gonorrhoea. The inflammation has been knoWn to extend from the urethra to one of the cavernous bodies','in which case a hard fusiform swelling, tender upon pressure and due to the effusion of plastic lymph, is felt upon one side of the penis. As the inflammation subsides the tenderness disappears, but the tumor is apt to remain, and, in con- sequence of its interference with the distention of the organ in erection, the penis may assume various curves and the act of coitus be seriously interfered with. During the inflammatory stage of gonorrhoea abscesses sometimes form in the cellular tissue covering' the urethra, either anteriorly to the scrotum, or in the perinaeum; and may attain a very con- ' MiiiTON on Gonorrbcea, p. 75. 56 UEETHEAL GONOEEHCEA IN THE MALE. siderable size. If left to themselves, they are liable to break within the canal and give rise to urinary abscess and fistula. It is chiefly during the second stage of gonorrhoea that buboef are met with, if they occur at all ; for they are rare compared with the number of patients afflicted with this disease. According to the statistics of the Antiquaille Hospital at Lyons, an attendant bubo is met with in one out of every fourteen cases of gonorrhoea.' They are at once recognized by the physician and patient by the enlargement and tenderness of one or more glands in the groin, occasioning considerable pain and uneasiness in walking, and standi ing. Buboes attendant upon gonorrhoea, uncomplicated, with chan- croid, |,re sympathetic buboes ; of which a fuller description will be given hereafter, when speaking of buboes in general. They may generally be made to disappear in a few days by keeping the patient quiet and producing a little counter-irritation by painting the skin over them daily with tincture of iodine. It is only in scrofulous subjects, or in consequence of violence, excessive fatigue or general depressing influences, that they ever exhibit a tendency to suppu- rate. I have known of one instance of a man suffering from gonor- rhoea, who after exposure to great hardship upon a wreck, had a suppurating bubo that confined him to his bed. for six months. Inflammation of the lymphatic vessels running along the dorsum of the penis is still another complication of the acute stage of gonorrhoea, and one which is also met with in comiectipn with chancroids. It is to be carefully distinguished, as we shall see here- after, from the induration of these vessels which often attends an indurated chancre. " It occupies the same vessels and the same situation, and presents the same forms as the latter ; but is distin- guished from it in several ways : 1. By its feel, which is like that of an hypertrophied cord, elastic but not cartilaginous. 2. By the fact that the cellular tissue uniting the vessels generally participates in the inflammation, , and thus binds together in a large cord, the dorsal vein, the lymphatics, and the artery, rendering it difficult to distinguish the inflamed lymphatics from the bloodvessels. 3. By the pain,. generally severe, which it expites, and by the swelling and redness visible over the course of the inflamed vessels, caused by the extension of the inflammation to. the skin."^ This inflammation . of the lymphatics on the, dorsum of the penis sometimes gives rise in chordoe, with the concavity of the- arc looking upward. The second stage of gonorrhoea, which we have now described, is 1 Gaz. dee Hfipitaux, No. 141, 1861. 2 Basserkau: Affections de la Peau Symptomatiques de la Syphilis, p. 160. SYMPTOMS. 57: variable' in its dnration in different subjects. As a general rule, it lasts from one to three weeks, being inflxienced by the constitution of the individual, his mode . of life and the number of his previous attacks. It is succeeded by the third stage or stage of decline. This final stage of acute gonorrhoea is marked by no peculiar symp- toms, and is' characterized only by the. disappearance of the more acute symptoms and a gradual return to a condition of health. The discharge runs through the same phases, in an inverse order, which it did at the outset of the attack. It gradually becomes less and less purulent, and finally is almost wholly mucous, before completely disappearing. Perhaps the most valuable indication of the ushering in of this stage of gonorrhoea is the marked diminution or entire cessation of the pain in passing water. The painful erections and chordee may continue after the acute inflammation has subsided, since it takes time for theplastip matter effused around the urethra to be. ab- sorbed. We have reason to believe that in the course of an attack of gonorrhoea, the disease gradually extends from the outer to the deeper portions of the canal, and it is in this latter situation that it is prone to lurk for an indefinite period. After the discha,rge has lasted for several weeks, we may evacuate the whole of the spongy portion by pressure from behind forward in front of the scrotum, and then, when no further discharge can- be made to appear, we can still produce it by the exercise of similar pressure on theperinseum. In some instances, the inflammation extends to the mucous mem- brane of the bladder. The duration of the final stage of gonorrhoea is, as a general rule, longer than either of the preceding. It may be cut short by treat- ment, but, if left to itself, commonly lasts for weeks or even months. Gronorrhoea is a disease which, independently of treatment, rarely terminates in less than three months. Thus far I have said nothing of the reaction of this disease upon the general system. This varies greatly in different individuals and in different attacks in the same person. In some rare cases there is considerable febrile excitement during the inflammatory stage, marked by the usual symptoms of headache, dry skin, full pulse, farred tongue, etc. As a general rule, however, there is but little constitutional disturbance, and after the acute symptoms have passed, the invariable tendency of the di^ase is to depress the general health. This fact should be remembered in the treatment. A first attack of gonorrhoea is usually more acute than subsequent 58 UEETHEAL GONOEEHCEA IN THE MALE. oues ; tlie . latter often being subacute or chronic from the first. They are also more difficult to be influenced by remedies, and show a decided tendency to run into gleet. Cases of gonorrhoea have been reported, in which it has been said there was no discharge whatever — all the othei- symptoms of gonor- rhcBa being present, and the disease following impure coitus. These have been called cases of dry gonorrhoea. I doubt whether there be a total absence of all secretion in these cases throughout thejr whole course, but can readily conceive of an inflammation of the mucous membrane of the urethra, resembling that of erysipelas upon the skin, in which the secretion is for a time but slight, and incapable of detection except by a careful examination of the urinfe. As the inflammation subsides, however, I should expect to find dis- tinct traces of a discharge. We have analogous symptoms occa- sionally in inflammations of the pituitary membrane of the nose. Two cases of this variety of gonorrhoea are reported by Dr. Beadle in the New York Journal of Medicine and Surgery, for October, 1840. Causes and N"atuee of Gonoeehoba. — ^Every one is aware that urethral gonorrhoea in the male often proceeds from direct conta- gion, or, in other words, from intercourse with a woman affected with the same disease. But there is another mode of origin, ad- mitted by nearly every writer, as of at least occasional occurrence, but with regard to the frequency of which some difference of opinion has been expressed. I refer to gonorrhoea originating in coitus just before, after, or during the menstrual period, or with a woman suffer- ing from leuoorrhcea, and, in a few instances, when nothing whatever abnormal can be discovered in the female genital organs, and the disease in the male can only be attributed to the irritant character of the vaginal or uterine secretions. I have been convinced, by a somewhat extended observation, that goporrhoea originating in this mode is of very frequent occurrence. Of one thing I am absolutely certain, that gonorrhoea in the male may proceed from intercourse with a woman with whom coitus has for months, or even 5rears, been practised with safety, and this, too, without any change in the condition of her genital organs, percepti- ble upon the most minute examination with the speculum. I am constantly meeting with cases in which one or more men have cohabited with impunity with a woman both before and after the time when she has occasioned gbnorrhcea in another person ; or, less frequently, in which the same man, after visiting a woman for a long ^leriod with safety, is attacked with gonorrhoea without any disease CAUSES AND NATURE OF GONORRHCEA. 59 appearing in her, and after recovery resumes Ms intercourse \vith her and experiences no farther trouble. The frequency of such cases leaves no doubi; in my mind, that gonorrhoea is often due to accidental causes, and not to direct contagion. In many of the instances referred to, the woman is suffering from a frequent combination of symptoms met with in practice, viz., general debility, engorgement of the cervix uteri, and more or less leucorrhoea ; but her previous history, and the impunity with which her favors have been bestowed for a long period, preclude the idea that her discharge is the remains of a previous attack of gonorrhoea to which it owes its contagious property. Moreover, such an expla- nation fails to cover other instances, in which there is no appearance whatever of leucorrhoea, and the genital' organs, so far as we can discover, are in a state of perfect health ; although intercourse about the tinie of the menstrual period has given rise to gonorrhoea in the male. The greatest obstacle to the admission of gonorrhoea independenv of contagion appears to be the rarity of urethritis in married men compared with the frequency of leucorrhceal discharges in their wives. As proved by unquestionable cases occurring in my own practice and in that of my medical friends, husbands do not always escape. That they are not more frequently affected is sufficiently explained by the immunity conferred against all simple irritants by constant and repeated exposure, whereby " acclimation " — ^to use a term adopted by the French — is acquired. The same fact is observed when neither the church nor the state has sanctioned marital rela- tions ; since it is not generally the habitual attendant upon a kept mistress affected with leucorrhoea who suffers, but some fresh comer who shares her favors for the first time. My friend. Dr. B. Fordyce Barker, whose extensive experience with female diseases is well known, and who has thus had the Op- portunity of studying this subject from an opposite standpoint to ipj own, tells me that he has noticed a peculiar form of inflamma- tion of the) lining membrane of the uterus, in which the uterine discharge loses its alkaline reaction, becomes decidedly acid and acrid, and irritates and excoriates the mucous membrane of the vagina and the surface of the vulva. He adds, that, in numenrous instances in married life, he has known this discharge to excite urethritis in the male between parties whose fidelity was unques- tionable ; and he has related to me a number in detail which I would gladly repeat, if space permitted. Most cases of gonorrhoea from leucorrhoea or the menstrual fluid 60 UEETHEA'L GONOKEHCEA IN THE MALE. present no characteristic symptoms by ■whicli they can be distin- guisbed from tbose originating in contagion; The contrary: is frequently asserted, and it is said tbat the former class may be recognized by tbe mildness of tbe symptoms, the short duration of the disease, and the absence of contaigious properties. I am familiar with the slight urethral discharge unattended by symptoms of acute inflammation, and disappearing spontaneously in a few days, which sometimes follows intercourse with women affected 'with leucorrhcea; but such instances are far less frequent than those in which the dis- ease is equally as persistent and as exposed to complications as any case of gonorrhoea from contagion. Some of the most obtstinate cases of urethritis I have ever met with have been of leucorrhoeal origin, and have terminated in gleet of many months' duration. Diday has even set apart those cases of urethritis which originate ir the menstrual fluid as constituting a distinct class, characterized by their greater persistency and obstinacy under treatment than cases of gonorrhoea from contagion.^ Those who maintain the non-contagious character of urethral dis- charges of leucorrhoeal origin have failed to adduce the slightest proof in favor of their assumption, and it may safely be asserted that none of them would venture to make a practical application of their principles. The contagious character of the leucorrhoeal secre- tion is already proved by the existence of the disease in the male ; why should not the same property be continued another, still another, and any number of removes from its origin ? This suppo- sition is sustained by analogy, since no fact is better established than that catarrhal conjunctivitis may be communicated from one person to another until all the members of a family, school, or asylum have become affected. At our public institutions for dis- eases of the eye such instances' are very common, and the physicians of "our children's asylums are well aware of the difficulty of eradi- cating muco-purulent conjunctivitis which has once sprung up among the inmates. At an orphan asylum, under the charge of my friend, Dr. Learning, this disease was introduced by a single child^ brought from Eandall's Island, and spread to twenty-tWo others before it could be arrested. Again, the leucorrhcea of pregnancy is sufficient to give rise to ophthalmia neonatorum : would any one, presuming upon its leucorrhoeal origin, dare to apply a drop froiri the infant's eyes to his own? Several instances are recorded in which physicians have lost the sight of an eye with which the dis- 1 Arch. Q6a. de M^d., Oct., 18P1. CAUSES AND NATURE OF GONOEEHCEA. 61 charge of ophthalmia neonatorum has inadvertently been brought in contact. The views which I have here advocated relative to the frequency of gonorrhoea independent of contagion, are by no means novel, and are entertained by many of our most eminent authorities, espe- cially among the French, who possess unequalled advantages for investigating the etiology of venereal diseases.' The importance of this truth whenever a physician in the exercise of his profession incuTs the fearful responsibility of passing judgment upon the virtue of a woman; and thus affecting her reputation and happiness (and often that of many otJiers with whom she is con- nected) for life, cannot be overrated. In all such cases, the accused should receive the benefit of any doubt which may exist ; and the physician who withholds it from her out of a morbid fear that he may be imposed upon,' and thus runs the risk of convicting an inno- cent person, is unworthy of his calling. His province is to decide from the symptoms taken in connection with the known facts of the case, and unless these are sufficient to establish guilt beyond the shadow of a doubt, humanity demands at teast a verdict of " not proven." Other causes, in addition to those already mentioned, may give rise to urethral gonorrhoea in the male. Thus, unquestionable instances are reported in which a gouty or rheumatic diathesis without exposure in sexual intercourse has occasioned a discharge from the urethra. Eicord relates a remarkable case of tubercular deposit in differ- ent portions of the urethra of a strumous subject jvith symptomatic urethral discharge ; ' and a scrofulous diathesis is generally a strong predisposing, if not an active cause of inflammation of the urethra as well as other mucous canals. Mr. Harrisoii reports the case of a medical practitioner who- suf- fered from a puriform discharge, heat and pain along the course of the urethra, attended with frequent micturition, chordee, and sympa- thetic fever, after eating largely of asparagus.' Among other causes of urethritis are free indulgence in fermented liquors, terebinthinate medicines, paraplegia inducing changes in ' Consult RicoED, Lettres sur la Syphilis, 2d edition, p. 29. Didat, Nourelles Doc- trines sur la Syphilis, p. 515. Fodbniee, De la Contagion Syphilitique, p. 111. Sir Heitet Thompson, Stricture of the Urethra, p. 120. Mr. Skey, London Medical Ga- zette, vol. xxiii. (1838-39), p. 439. " Bulletin de I'Acad. de Mgd., vol. xv. p. 565. ' Loudon Lancet, Am. ed., Jan., 1860. 62 URETHRAL GONORRHCBA IN THE MALE. the urine, tlie use of bougies, stricture, masturbation, prolonged excitement of tte genitals, cancer of tbe -womb, vegetations within the urethra, ascarides in the rectum, dentition, epidemic influences, etc. The internal use of cantharides is peculiarly liable to excite gonorrhoea, which, in this case, commences in the deeper porl ion of the canal. M. Latour, editor of the Union Medicale, vouches for the truth of ihe following story: A physician, thirty years of age, had been continent for more than six weeks, when he passed an entire day in the presence of a woman whose virtue he vainly attempted to overcome, but who resisted all his approaches. From ten o'clock in the morning until seven in the evening, his genital orgafis were in a constant state of excitement. Three days afterwards he was seized with a very severe attack of gonorrhoea, which lasted for forty days. A chancre within the urethra is attended with more or less thin and often bloody discharge, which will be more particulaiiy de- scribed in a subsequent portion of this work. Again, urethral disoilarges are sometimes due to changes in the mucous membrane lii^ng the canal, induced by infection of the constitution with the sjpphilitic virus. In several instances I have observed a muco-puruleJt discharge coinciding with the first out- break or a relapse of secondary symptoms, and so long after the last sexual act that it could not be attributed to the ordinary causes of gonorrhoea. Bassereau speaks of similar cases.^ There is no more frequent seat of early general manifestations than the mucous membranes in general ; .and in the cases referred to changes probably take place in the urethral walls similar to the erythenia, mucous patches, and superficial ulcerations which are found within the buccal and nasal cavities. These .cases are very rare, and can only be distinguished from ordinary gonorrhoea by the previous history and coexisting symptoms of the patient. For instance, if there has been no expbsure for a long period, and especially if secondary symptoms have recently made their appearance upon other mucous membranes, the urethral discharge is probably symptomatic of the constitutional disease. Since the secretions of secondary lesions are now known to be contagious, the discharge in these cases is doubtless so, also; it is not susceptible ofdnoculation upon the person from whom it is derived nor upon any other affected with ' .\ifectious Syphilit.iques de la Peau. p. 356. TREATMENT. 63 sjpMlis, but, if communicated to a healtliy individual under the requisite conditions, will give rise to a chancre. The inferences from what has now been said of the etiology ol' gonorrhoea relative to its nature, are so obvious that they require little more than mere mention. If in a large proportion of cases llie disease can be traced to no other cause than leucorrhcea, the menstrual fluid, or, in less frequent instances, to excessive coitus, intercourse under circumstances of special excitement, inattention no c'eanliness, the abuse of stimulants, etc., and if, when thus ori- ginating, it is undistinguishable either by its symptoms, course complications, or termination, from the same affection due to con- tagion, it is evident that it should be ranked among the ordinary catarrhal inflammations of mticous membranes, or, in other words, that it is a simple urethritis, the connection of which with sexual intercourse is a merely accidental, or at all events, not a necessary circumstance. But — it may be asserted — ^the possibility of contagion proves xhe presence of a poison. Granted : but it does not follow that it is a specific poison, or one incapable of being produced by simple inflam- mation. Such a conclusion would be contrary to the facts adduced in the preceding pages, and, moreover, is not required by the analogy of inflammations of other mudous membranes ; since, in miico-puru- lent conjunctivitis — the true analogue of gonorrhcea — we have pre- cisely the same order of events, viz., inflammation originating in simple causes, and giving rise to a secretion which is contagious ^and capable of transmission through an indefinite series of indivi- duals. The discharge from the two mucous surfaces just mentioned would even appear to be transferable, since that from the urethra applied to the eye gives rise to purulent ophthalmia, the secretion of which, if we may rely upon a few experiments , by Thiry, of Brussels, will, when brought in contact with the lining membrane of the urethra, produce urethritis. I have no space to discuss the untenable theory of a " granular virus" of gonorrhoea advanced by M. Thiry, according to whicn, the presence of granulations upon the mucous membrane is neces- sary to render the discharge contagious.' Teeatment. — The treatment of gonorrhoea must be adapted to the general condition of the patient, and especially to the stage ot ' M. Tiiiky's views have been published in a serie? of lectures in the Presse M^d B^lge, and are also advocated by Guyomar, Thfess do Paris, 1858 (No, 282). 6-i URETHRAL GOITORRH(EA IN THE MALE. his disease. In the great majority of cases met vrith in practice, acute inflammatory symptoms have already set in at the time the patient first applies to the surgeon ; but in those exceptiOi-al cases which are seen at an early period, and in those only, "we may often succeed in cutting short the disease by means of the treatment termed abortive. Abortive Treatment of the First Stage. — ^During the first few days after exposure, varying in number from one to five in difierent cases, before the symptoms have become acute, when the discharge is but slight and chiefly mucous, and while as yet there is no severe scalding in passing water, we may resort to caustic injections with a view of exciting artificial inflammation Avhich will tend to subside in a few days, and supplanting the existing morbid action which is lia,ble_to continue for an indefinite period and is exposed to various complications. This is known as the " substitutive," or more com- monly as the "abortive treatment" of gonorrhoea. This method has been inordinately praised and as violently attacked; its true merit is probably to be found between these two extremes. It is certainly liable to be greatly abused, and, if so, is both unsucceesfui and capable of pj-oducing the most unpleasant consequences; but when limited to the early stage of gonorrhoea and used with proper caution, it is a highly valuable method of treatment, unattended with danger, and undeserving the censure sometimes cast upon it. In employing the abortive treatment, there are several points which it is important to recollect : 1." The disease, in the stage to which this treatment is applicable, is limited to the anterior portioi/ of the urettra, known as the fossa navicularis, or extends but a short distance beyond it; it is not necessary, therefore, that the injection should reach the deeper portions of the canal. 2. For the treatment to be successful, the whole diseased surface should receive a thorough application of the injection, for if any portion remain untouched, it will secrete matter that will,again light up the disease. 3. When once a sufScient degree of artificial inflammation is ex- cited, the caustic has accomplished all that can be expected of it, and should be suspended. Since a solution of nitrate of silver, which is commonly used ir. the abortive treatment, is readily decomposed by contact with metallic substances, metal syringes should be avoided. Glass syr- inges, if well made, answer every purpose; but as found in the shops, they are apt to be unequal in calibre in different parts of the cylinder, the wadding of the piston contracts in drying, and a portion of the fluid fails to be thrown out, as is seen by its overflow TREATMBN'T. 65 wnen tlie syringe is filled a second timfj. For these reasons, I never advise a patient to purchase a glass syringe, knowing that it will probably give him much annoyance, and perhaps prevent his deriving benefit from treatment. Fortunately, we have a very excellent substitute in the hard-rubber syringes which can be obtained at the druggists'. "No. 1" (Fig. 1) is the one generally sold when no special form is directed by the surgeon, but its nozzle is objectionable; it is Kg. 1. unnecessarily long, its point is apt to irritate the internal wall of the canal, and it is not well adapted to fully distend the meatus. Fig. 2. "No. 1, A" (Fig. 2), is the form I usually recommend. The abrupt shoulder near the point is admirably adapted to fill the meatus, and the -short and rounded end cannot abrade the sensi- tive mucous membrane. Fig. 3. Fig. 3 represents another excellent form, and one which is recom- mended by Prof. Sigmund, of Vienna. Fig. 4. 66 URETHRAL GONOREHCBA IN THE MALE. The "uretliral syringe with extra long pipe" (Fig. 4) is, in fact, a syringe united to a catheter, and is adapted for injections of the deeper portions of the canal. The catheter portion may be bent to any curve desired by first oiling it and heating it over a spirit lamp; its form is then retained by dipping it in cold water. The solution of nitrate of silver, in the abortive treatment of gonorrhoea, may be of considerable strength, when only one injec-. tion will be required ; or, it may be weak, and in that case should be repeated at short intervals until the effect produced be deemed sufficient. I much prefer the latter course, especially with patients who apply to me for the first time, since it enables me to graduate the effect according to the susceptibility of the urethra, which' varies in different persons. The following is the formula for thn weak form of injection : — R. Argenti nitratis gr. j— iss. Aquae destillatse gvj. M. With this, as with all injections in gonorrhoea, it is essential to success that the surgeon should administer the injections to his patients, or see, by actual observation, that they know how to use them. Verbal directions cannot be relied upon. The patient should be made to pass his water immediately be- fore injecting, or, better still, a quarter of an hour before. "We wish to clear the urethra of matter, and to have the bladder empty so that the injection may have some tinie to act before it is washed away by another passage of the urine, and yet a short interval between the last act of micturition and the injection is advisable, in order that as much of the urine as possible may have drained from the canal and little be left to decompose the nitrate of silver. Ths prepuce should now be fully retracted, and the glans penis exposed. The latter should be wiped dry, so as to afford a firm hold to the thumb and forefinger of the left hand, applied to its opposite sides and firmly compressing it around the point of the syringe, intro- duced to its fall extent within the meatus. If this pressure be properly made, not a drop of the solution will be lost, as the piston of the syringe is slowly forced down by the forefinger of the right hand holding the instrument, and the whole contents will be dis- charged into the canal. The syringe should now be withdrawn, and the fluid still retained for a few seconds by continuing the com- pression of the glans. When the injection is all6wed to escape, it will be found to- be of a milky -white color. This is due to the TEEATMEISTT. 67 partial decomposition of the contained salt by the remains of the urine and the muco-pus in the canal. As this decomposition has prevented the, application of the injection in its full strength to the urethral walls, a second syringeful should be thrown in, and retained for two or three minutes. During this time a finger of the disen- gaged hand should be run along the under surface of the penis /rom hehind forwards, so as to distend the portion of the canal occupied by the injection, and insure the thorough application of the fluid to the whole mucous surface. The description of the method of using the syringe is, in the main, applicable to all the injections which may be required in, the course of a gonorrhoea ; but we are now speaking of the abortive treatment, by means of weak injections of nitrate of silver. We will suppose that this first injection has been administered by the surgeon, who, at the same time, has explained the various steps of the operation to the patient. The directions with regard to diet, etc., that will presently be mentioned in speaking of the second stage, should now be given ; the patient should be ordered to repeat the injection every three hours, and, for the present, it is best that he should be seen by thfe surgeon twice a day. It is also well at this time to prescribe an active purge. The first effect of the caustic injections is manifested in a few hours ; the discharge becomes copious and purulent, and consider- able scalding is felt in passing water. In the course of twenty-four to forty-eight hours, however, the discharge grows thin and watery, and, very likely, is tinged with blood. It is now time to stop the injection and omit all medication for a, few days, until we see how much good has been accomplished. If the treatment meets with its usual success the discharge will gradually diminish, and finally disappear in from three to five days. Sometimes, however, after growing less, it again increases, showing a tendency to relapse. Iq this case, I usually advise weak injections of acetate of zinc, as recommended in the third stage of the disease; Some surgeons prefer to resume the caustic injections in the same manner as at first, if, after a week has elapsed, any traces of the discharge remain. The chief objection to this modification of the abortive treatment is, that it is necessary to leave the administration of most of the injections to the patient, • who may be prevented by ignorance, or the requirements of his occupation, from using them as thoroughly or as often as is necessary. If we have reason to fear this, we may resort to a stronger solution, and inject it once for all, with our own hands, but I have found the effect decidedly less satisfactory. It 68 UEETHEAL GONOBEHCEA IX THE MALE. was this metliod of employing tlie abortive treatment that was Tecominended by Debeney of France, and Carmicbael of England, by whom this treatment was first introduced to the profession. The same method is also still employed and highly recommended by many surgeons, and especially by M. Diday of Lyons. The strong injection should not contain less than ten grains of the nitrate of silver to the ounce of distilled water, and more than fifteen grains are objectionable, unless with patients who have been under treat- ment before, and in whom the urethra has been found to be quite insensible. R. Argenti nitratis gr. x-xv. Aquae destillatae gj. M. The mode of using this injection is identical with that already described. Two small syringefuls should be thrown in ; the first to clear the urethra of urine and muco-pus, the second to exercise a curative effect ; and the surgeon should feel that the success of the treatment depends, in a great measure, on the thoroughness of its application. As an additional precaution against the fluid extend- ing further back than is necessary, the patient may compress the penis anteriorly to the scrotum, while the surgeon is administering the injection; or the same result maybe accomplished by making him sit astride the arm of a chair, and thus compressing the urethra in the perinteum. There is still another mode of employing a strong solution of nitrate of silver, by means of an instrument introduced by Dr. F. Campbell Stewart, of this city, and called by his name. • This instrument consists of a straight canula inclosing a sponge, which can be made to protrude from its extremity. This sponge is first soaked in a solution of nitrate of silver, and concealed within the canula. The instrument is then introduced for about two inches within the urethra, when the canula is to be partially withdrawn ■ the sponge is thus exposed to the contact of the urethral walls, in which position it is to be allowed to remain for a minute or two, and then withdrawn by slowly twisting it on its long axis. By the use of Dr. Stewart's instrument, the extent of the application can be limited at will, and it is perhaps owing to this fact that we can employ with safety a much stronger solution than when using a syringe. I have thus applied a solution of twenty, and even thirty grains to the ounce, without exciting an undue amount of inflam- mation, or other unpleasant symptoms. Care should be taken that the instrument be of sufficient size. Some of those found in the TREATMENT. 69 sliops are too small, not exceeding a No. 7" bougie in diameter. I have had one manufactured for my own use of the size of No. 10. I cannot leave this subject of the abortive treatment of gonor- rhoea, without again expressly stating that 1 recommend it only in the first stage of the disease, and not after acute inilammatory symp- toms have set in, or while the patient suffers from scalding in passing water. Taking the usual run of cases as met with in practice, probably not more than one out of ten is seen at a sufficiently early period to admit of the abortive treatment. Its employment in the acute stage, as recommended by its inventors, is generally unsuccessful, and dangerous and even fatal results have been known to ensue. Prudent practitioners have limited the use of caustic in- jections to the early stage of gonorrhoea, except in son^e instances in the decline of the disease; but, in the latter case, the mode of injecting must be modified, so that the fluid may reach the deeper portions of the canal. Treatment of the Acute Stage. — The proper regulation of the diet, exercise, and mode of life of the patient, is of the first importance in every stage of gonorrhoea. In the treatment of the inflammatory stage, as well as in the abortive treatment of the first stage^ if the patient can keep his bed for a few days, the battle is half won. The advantages of absolute repose and quiet should be placed proirii- nently before him, and every inducement be offered to lead him to avail himself of them. Yet in practice, we find that very few will submit to this constraint. It is very well to say that every patient that puts himself under the care of a physician, should follow his advice implicitly ia all things; but we must take the world as we find it, and the calls of business, or the necessity of secrecy, often render the insistence upon such stringent rules impossible. "When life is in danger, men absorbed in business will stay at home, but not merely for an attack of gonorrhoea. This, indeed, should not pi-event our doing our best to persuade them, but we shall succeed in but a small minority of cases. Exercise of all kinds should be avoided as much as possible, walking, dancing, riding on horseback, and standing — in the street, at the desk, at a party— are all injurious. Eiding is certainly less objectionable than walking, and yet a long ride, even in a rail-car. often aggravates a gonorrhoea or induces a relapse when it is appa- rently cured. At home, .and at the store or office, the recumbent posture should be maintained as much as possible. It is highly important, also, that the genital organs should be well supported by a suspensory bandage. The kind of bandage is immaterial, prodded 70 UEETHEAL GONOBEHOSA- IN THE MALE. it fit well and do not chafe the parts; and of these conditions the surgeon should satisfy himself by actual observation. While the more acute symptoms continue, the diet should be exclusively fari- naceous; and meat, stimulants, asparagus, cheese, coffee, and acids be forbidden. The perusal of all books calculated to excite the passions, and the company of lewd women, even if no improprieties be committed, should be strictly interdicted. The last-mentioned caution is not generally given without good reason. At the commencement of the treatment of a case of gonorrhoea in the acute stage, it is well to administer an active purge, as five grains of calomel combined with ten of jalap, a full dose of Epsom salts, or three or four compound cathartic pills of the U. S. P. If the inflammatory symptoms be severe, marked benefit will be de- rived from the application to the perinseum of half a dozen leeches, which, however, are rarely absolutely necessary. Care should be taken to keep the head of the penis free from any collection of mat- ter, lest balanitis be excited or the disease be aggravated by its pre- sence. A pair of triangular-shaped drawers, like ordinary swimming drawers, worn next the skin, affords the best protection tp the patient's linen. "Water, as hot as can be borne, is the most grateful local application that can be used. I have found that it generally affords great relief to the scalding in micturitioa and the local pain and uneasiness, and can fully indorse Mr. Milton's statement witli regard to it. " The only direct application which I can safely say has never disappointed me, which is at once safe, simple, and use- ful, is that of very hot water to the penis. But to obtain the really good effects it offers, the water must be hot, not lukewarm. In fact, we seldom see so much good ensue as when it is carried to the ex- tent of producing some excoriation and faintness ; thus applied, and especially in the early stages of the disease, the weight felt about the testicles soon disappears, the pain on making water and iising injections is soothed, and the prepuce and glans rapidly regain a more normal temperature and color.'" The best method of employ- ing it is to direct thi patient to immerse his penis in a cup of hot water for a few minutes before and after using the injection. After the operation of the cathartic, we may, in most cases, coni- mence at once with copaiba or cubebs, rules for the exhibition of which will presently be given at length. If, however, the peni^ be still much sTTolleUj and the scalding on passing water severe, we may defer the exhibition of the anti-blennorrhagics for a few ^^ays ' Milton on Gouorrhoea, p. 21. TEEATMEN.T OP THE ACUTE STAGE. 71 and administer alkalies or diuretics, either alone or combined witli sedatives, for the purpose of rendering the urine less irritating by diminishing its acidity, or diluting its contained salts by increasing its quantity. Again, both these classes of remedies may be given at the same time. From one to two drachms of the chlorate, acetate, or nitrate of potash, or two or three drachms of liquor potassse, may be added to a pint of flaxseed tea; and the patient be directed to take this quantity in the course of twenty-four hours. The folio 'v- ing is also an excellent formula : — : R. Potassse bioarbonatis Jij. Tinoturse hyosoyami Jj. Muoilaginis 5 v. M. A tablespoonful every three hours. Do not mix tincture of hyoscyamus and liquor potassse in the satne prescription, since the effect of the former is destroyed by the pr'esence of a caustic alkali.' In this stage of the disease, Mr. Milton highly recommends the following : — R. Pulv. potasssB chloratis gij. Aquae bullientis gv. Misoe et adde — Liquoris potassas ^iij. Potassse acetatia giij ad Jv. Misce et cola. One ounce three times a day. If the bowels be not freely open, Mr. Milton adds powdered rhu- barb to each dose of this mixture, in suf&cient quantity (gr. v ad 3j) to produce two or three loose stools daily. The following is another formula recommended by Mr. Milton : — R. PotassEB acetatis gj. Spirit setheris nitrici giij. Aquse camphorae gvj. M. One ounce three times a day. An elegant and convenient method of administering an alkali ia by means of Brockedon's wafers of bicarbonate of potassa, of which two may be given after each meal. The only objection to them is their expensiveness. 1 See Paris's Pharmacologia, Ninth Edition, p. 512. This fact has recently been brought forward as new, and confirmed by actual experiment, by Dr. Garkod-; .Mcdico-Ohirurgical Transactions, Second Series, vol. xxiii. London, 1858. 72 URETHRAL GONORRHCEA IN THE MALE. If the penis be much swollen and florid, the meatus contracted by the distention of its -walls, and the urethra very sensitive, the above general measures should constitute the only treatment, and no local remedies, with the exception of hot water, be re- sorted to, until the inflammation has somewhat subsided. In the majority of eases, however, especially when the patient has had gonorrhoea before, the local symptoms are noi! severe, even in the acute stage, and the point of a syringe can be gently introduced' within the canal without exciting much pain. When this is the case, an injection containing glycerine and strongly opiated, will be found to afford great relief to the local pain and uneasiness, and hasten the subsidence of the inflammatory symptoms, and the ' diminution of the discharge. I can speak very decidedly in favor of this application and of its perfect safety ; but the opium must not be added in the form of tincture, or the alcohol, which is an irritant, will counteract its effect ; and the fluid is to be injec^d with gentleness, and not with such force as to painfully distend the canal. The following is the formula that I use : — R. Extraoti opii 9j Glyceriiise §j. AqusB §ijj. M. Injection to be used after every passage of urine. In many cases of a subacute form, half a grain or a grain of acetate or sulphate of zinc may be added to each ounce of the mixture, even at the outset, and there are but few calses in which it is not admissible in the course of twenty-four or forty-eight hours, when the inflammation, loeal pain, and scalding are generally found to be much improved. If the case continue to progress favorably, the quantity of the astringent may be gradually increased, and that of the opiate diminished ; and the treatment should be continued according to the rules laid down for the third stage, to be mentioned presently. While pursuing the treatment of the acute stage of gonorrhoea, care should be taken that antiphlogistic measures be not too long persevered. ,,^ith. It should be remembered that the natural ten- dency of the disease is to lower the tone of the system, and a con- dition of debility in turn reacts on the disease and prolongs its duration. We often meet with patients who have treated them- selves with low diet and daily purging for weeks, and yet who are no better of their gonorrhoea. An antiphlogistic course alone may relieve the more .acute sympton^, but it will not cure the complaint- TEEATMEXT OF THE STAGE OF DECLINE. 73 and so soon as the. pain m passing water lias diminished and the loca] inflammation in a measure subsided, the patient should no longer be confined to his room, and should have a more liberal diet; nor, under any circumstances, should his confinement and abstinence be prolonged, if, after a reasonable time, they are found to produce no change for the better, or the pulse becomes feeble, the skin clammy, and the strength exhausted. Indeed, in some cases, in which the constitution is enfeebled by disease, debauch, or previous attacks of venereal, it is necessary to abstain from all measures calculated to lower the tone of the system, and resort to good living and even quinine, iron, and other tonics, from the very outset of the disease. It is, therefore, to be expressly understood that the antiphlogistic treatment here recommended, is intended to apply, in its full force, chiefly to the disease as it appears in first attacks in men of full habit. . Those patients who have had numer- ous previous attacks will rarely require such active treatment in any stage of the disease. The judgment of the surgeon must deter- mine the indications of each individual case. Treatment of the Stage of Decline. — A marked diminution of the scalding in making water, and of the painful sensations in the penis, is, I believe, a better index of the subsidence of the inflammatory action, than the character of the discharge, which, independently of treatment, often continues copious and purulent after the third stage has fairly commenced. In giving directions as to the regimen of a patient in the third stage of gonorrhoea, some regard should be paid to his usual mode of life. As a general rule, all indulgence in spirituous or malt liquors should be strictly forbidden, and total abstinence be prac- tised until the cure is complete, and for at least afortnight afterward. You will meet with some patients, however, who have been free drinkers for. years, and who will not well bear the total loss of their stimulus, without becoming so debilitated that their gonorrhoea is thereby prolonged and more difficult to cure. In these exceptional cases, it is better to allow a glass of claret, sherry, or even brandy and water, to be taken with the dinner. In any case, malt liquors should be avoided, since they are decidedly more injurious than other liquors which contain a larger amount of alcohol. The |iatient may now return to a more generous but simple diet, though salt meats, highly seasoned food, asparagus and cheese should still be avoided. The bowels are not to be .allowed to become consti- pated, and this should be prevented so far as possible by regulating the diet. One or two free stools a day are desirable. If the patiet" 7-f URETHRAL GOITOERHCEA IN THE MAI,,!!. have been confined to the house during the acute stage, he may now be allowed to go out, but should be cautioned against walking oi standing more than is necessary, and the genital organs should be well supported by a suspensory bandage. Patients often inquire whether the use of tobacco is injurious ; I believe that it is, and that either smoking or chewing, especially in excess, weakens the genital organs and tends to keep up a urethraldischarge. I have frequently been told by patients subject to spermatorrhoea, that smoking during the evening would invariably be followed by an emission during the night, and I am satisfied that many cases of gonorrhoea are pro- longed by the excessive use of tobacco. I therefore recommend entire abstinence, or, at least, great moderation, both in smoking and chewing, to persons suffering with this disease.' The chief remedies adapted to the third stage of gonorrhoea are injections, and copaiba and cubebs. By far the more important of these are injections, which constitute our chief reliance in the treat- ment of this affeiction, when it has arrived at this stage ; and, in spite of all that has been written and said against them, I do not hesitate to say, that the surgeon -who voluntarily renounces injec- tions, deprives himself of his best weapon in contending. with gonor- rhoea, and is comparatively impotent in his attempts to conquer it. The objections that have been raised against this mode of treat- ment need not long detain us. They are chiefly the following: 1. It is asserted that the iiyected fluid carries before it the muco-pus within the urethra, and thus extends the disease to the deeper por- tions of the canal. Supposing this possible in any case, it cannot take place, if the patient pass his water before injecting, as he should always be directed to do. 2. It is said that injections may excite swelled testicle and other complications of gonorrhoea. This is only possible, when they are used of too great strength or with undue violence. 3. It is supposed by some persons that there is danger of the injection penetrating the bladder. I formerly sup- posed that this was impossible with a syringe merely penetrating a short distance within the meatus, but, although I have since been convinced of my error by the fact that several patients of mine suf- fering from cystitis have been able to wash out the bladder with an ordinary Davidson's syringe, its point only introduced within the meatus, yet this result can only be attained by practice, and is not 1 Dr. Shipley has recently published two cases of gonorrhoea in which the dis- tifiargo repeatedly disappeared on leaving off smoking, and returned on resuming it. (lioetoH Med. and Sury. Journal, Nov. 22, 11 60. J TEEATMEITT OF THE STAGE OF DECLINE. 75 at all likely to occur in tlie ordinary mode of using urethral syringes. Moreover, no harm would ensue even if a portion of the fluid should enter this viscus, for it would be immediately neu- tralized by the urine. 4. The chief objection that has been alleged against injections isj that they are a frequent cause of stricture of the urethra. This the opponents of injections have endeavored to prove, by shiawing that most persons with stricture preceded by gonorrhoea, were treated for the latter disease by injections. This is clearly a mode of reasoning, ;post hoc ergo propter hoc, and by no means proves the ground assumed. I have heard of some one, who, to show its fallacy, instituted some inquiries among patients with stricture, as to whether they had taken flaxseed tea for their previous gonorrhoea, and who was able to prove, if such reasoning be reliable, that flaxseed tea is a very fruitful source of stricture. As Eicord justly states, it is much more probable that strictures are due to the chronic inflammation, which, in cases of gonorrhceal origin, has usually preceded them for a long period, than to any influence exer- cised by injections. This well known effect of chronic inflammation of a mucous membrane in producing an effusion of plastic material in the sub-mucous cellular tissue which by its contraction dimin- ishes the calibre of the canal, is a strong argument in favor of this view. The objections to the use of injections are, I believe, founded on their abuse, on false reasoning, or on prejudice, and will not stand the test of examination. When properly used, these are the most valuable means within our reach for. the cure of gonorrhoea, and are employed in the practice of all surgeons, with very few excep- tions, who have had the opportunity of testing their value. Injections are particularly adapted to the treatment of the first stage by the abortive method and to the treatment of the third stage of gonorrhoea ; although, as already stated, in very many cases they may be used with safety and benefit in a weak form, even in the second or acute stage. These remarks in favor of injections do not of course imply that they are infallibly successful, nor that they can be used indiscrimi- nately in all cases. Under certain circumstances, their effect is found to be injurious. If in the course of treatment the patient complain of a frequent desire to pass his urine, and other symptoms indicating irritation or inflammation of the neck' of the bladder or prostate, injections should be at once suspended. Continuous pain in the penis, or any considerable amount of tumefaction of its tissues also contra-indicates the use of irritant or astringent injections, although the formula containing glycerine and extract of opium 76 URETHRAL GONOEEHCEA IN" THE MALE. which was recommended in the acute stage, may still, in many cases, be employed with advantage. Moreover, it should not be forgotten that injections will sometimes keep up a discharge through the irritation which they excite, however simple may be their composi- tion. After the force of the disease has been subdued, they should therefore be used at gradually increasing intervals, or, from time to time, be altogether omitted, until the necessity of their continu- ance again becomes apparent. The manner of using the syringe in the third stage is essentially the same as in the abortive treatment of the first stage. A larger syringe, however, should be employed, one, for instance, holding three or four drachms ; since there is now no necessity of limiting the action of the injection posteriorly, and, on the contrary, it is desirable to extend it as far back as possible, in order that it may reach the whole diseased surface. For this purpose the finger may be run along the under surface of the urethra from before back- wards, as well as in the opposite direction (from behind forwards), as previously recommended, in order to insure complete distention of the canal and exposure of its lacunae. The patient should always pass his water before injecting, and throw in two syringefuls at each application. A great variety of substances have been recommended as the active principles of injections. A choice, to a certain extent, is doubtless desirable, since the same injection docs not always suc- ceed equally well in all cases. For instance, one of my patients, whom I have repeatedly treated for gonorrhoea, is always made worse, by an injection of sulphate of zinc, and is benefited by a weak solution of nitrate of silver. Peculiarities of this kind are occasionally met with, but I believe that much time is wasted by young practitioners in changing from one to another of the many varieties of injections proposed in books, under the supposition that some specific effect is to be obtained from the contained ingredients, whereas, in most cases, success depends upon the thoroughness of the application, and attention to the general health and any existing complications. My own preferences for an astringent in the active principle of injections in the third stage of gonorrhoea, are very strongly in favor of the acetate of "zinc, which is also the favorite injection of Sig- mund of Vienna, Mr. Milton, and many other eminent surgeons. I have already spoken of the addition of a small quantity' of this salt, to the sedative injections of the acute stage, after the more inflam- matory symptoms have been subdued. The proportion of the ace- TREATMENT OF THE STAGE OF DECLINE. 77 tate may be increased and that of the opiate diminished, as the case progresses, and the latter finally be omitted altogether. The strength of the injection should be such that it may excite a slight uneasy sensation in the urethra for five or ten minutes, but it must not be strong enough to cause severe or long- continued pain. As the case approaches a cure, the injection will cease to excite any unpleasant feeling whatever, and its strength need not be farther increased. In most cases, we need not at any period exceed the proportion of the acetate in the following formula: — B- Ziiici acptatis gr. xij. Aquae §i7. M. Glycerine may be substituted for half an ounce or an ounce of the' water. As to the frequency with which the injection is to be used, I usually direct the patient to inject after each passage of his urine, with the expectation that he will take four or five injections in the course of the twenty -four hou^s. It is better that the last injection should be applied an hour or two before retiring, since if used di- rectly before going to bed, it favors the occurrence of erections and chordee during the night. If the discharge do not materially diminish under the use of these injections, either alone or combined with the internal administration of copaiba or cubebs, I usually resort to a solution of nitrate of silver, of the strength of from two to five grains to the oxmce of water, and mject it myself for the patient, daily, or every two or three days, while at the same time he is directed to continue his injection of sul- phate of zinc. The effect of an irritant like nitrate of silver should be closely watched, and its administration should not, therefore, be left to the patient himself. The sulphate of zinc is nearly, though not quite as valuable a remedy as the acetate, and the remarks above made in favor of the latter are in a measure applicable to the former. Indeed, if I were asked to name the simplest treatment of gonorrhoea, and the one best adapted to the largest number of cases, I should reply : a weak injection of the sulphate or acetate of zinc, containing from one to three grains to the ounce of water. Many inen about town constantly carry in their pockets a prescription of this kind (generally with the addition of a little morphine or a few grains of powdered opium), with which they almost invariably succeed in arresting their frequent attacks of gonorrhoea, without resorting to the nauseous anti-blennorrhagics, or finding it necessary to consult a surgeon. A great reputation has been acquired for a reddish powder sold by an irregular practitioner 78 URETHRAL GONORRHCBA IK THEMALE. of tMs city, wlio tells his patients that the ingredients are entirely unknown to the profession. This powder, subjected to chemical analysis, is found to contain as coloring matter Armenian bole, and as an active ingredient acetate of zinc. The sulphate of zinc was a favorite with Dr. Graves, who was in the habit of combining it with the impure carbonate of zinc, as in the following formula : — R. Zinci sulphatis gr. iij. CalaminaB gr. x. Mucilaginis jij. AquiB 3vj. JI. With regard to the addition of calamine. Dr. Graves says : " How the lapis calaminaris acts, unless on a mechanical principle, it is diffi- cult to explain ; but of its utility I am certain, having long used this combination, as recommended in Thomas's Practice of Physis." ' The chloride of zinc is a powerful^ caustic and irritant which fill fils, although in a much less perfect manner, the same indications as nitrate of silver, and may, therefore, be used under similar circum- stances. Of the numerous other formulae for injections sometimes employed in the treatment of gonorrhoea, the following are among the best : — R. Cupri sulphatis gr. xij. Aquae 5iv-vi. M. , R. Liq. plumbi subacetatis Jss-j. Aquse §iv-TJ. M. R. Aluminis gr xij-xxx. Aquse giv. M. Mr. Milton says of alum : " The absence of pain which follows its use, and its feeble curative power, have led me to assign to it only a secondary ra&k. I am, indeed, extremely doubtful, if it possess any superiority over very mild injections of nitrate of silver or sulphate of zinc, and would, therefore, confine its exhibition to those cases accompanied by severe pain, where it may, during a day or two, serve as a pioneer to the others." In the following we have a combination of alum and sulphate of zmc :- 1 Clinical Lectures, London Med.Gaz., new aeries, vol. i., 1838-9, p. 438. TREATMENT OF THE STAGE OF DECLIITE. 79 >' _ B- IJiq- aluminis comp. gj. AqusB giij. M. The two following are excellent formulae nmcli employed by Eicord : — R Zinoi sulphatis, Plumbi acetatis, aa gr. xxx. Aquse rosse gvj. M. R. Zinci sulphatis gr. xv. Plumbi acetatis gr. xxx. Tincturse catechu, Vini opii, aa gj. Aquae rosse 5vj. M. Vegetable astringents aiay also be employed either alone or in combination with the salts of the metals, but are in general inferior to the latter. R. Vini ruhri gvj. > Acidi tannici gr. xviij. M. R. Zinci sulphatis, iicidi tannici, aa gr. xij. Aqu£E 5iT. M. Tannattf of zinc is formed by decomposition of the sulphate. R. Potassse permanganatis gr. xxxyj. AqusB gvj. M. (Dr. John G. Eich, of Canada.) The formula for the " Matico (?) injection," as commonly sold by that name, is as follows : — R. Zinci acetatis gr. Tj. Morphise acetatis gr. j. Acidi tannici gr, iij. ■ Aq. flor. aurantii gj. Aqase, q, s, ad §j. M, Injections of tincture of aloes are recommended by Gamberini,^ of Bologna, who states that they excite only a momentary smarting sensation, and are very ef&cacious, R. Tinct. aloes |ss. Aquse,|iv, ' M, ' Kev. de Ther, Med.-Chir,, Jan, 1, 1860, p, 13,, 80 UEETHEAIi GOXOEEHCEA IN THE MALE, The subnitrate of bismuth is an excellent injection. It acts as a local sedative, and, deposited upon the walls of the urethra, serves to protect the diseased surfaces from contact. Of 52 patients treated exclusively with injections of subnitrate of bismuth, 36 recovered after an average treatment of twenty-two days.' I have found only one difficulty attending its use, viz., that it clogged up the urethra, and by its mechanical presence excited an uneasy sensation, which was only relieved by the passage of the urine. As it is not soluble in water, it should be suspended by means of common mucilage, or better still (on account of the liability of the former to become rancid) mucilage of sassafras or quince seeds, or glycerine, and the bottle be shaken before using. K. Bismuthi subnitratis 5j- Macilaginis cydonii §ss. Aquae ^vss. M. Dr. Irwin (U. S. Army) relies upon an injection of chlorate of potassa (3i ad aquse Sviij), repeated every hour for the first twelve hours, and gradually decreasing the frequency until the second or third day, when he states, " the disease will be generally found to have ceased." ? Mr. Gr. Borlase Ohilds employs an injection of the liquor hydrar- gyri nitratis (itLss ad aquse |i), repeated three times a day. Western eclectics, so-called, often use hydrastin, either alone or combined with leptandrin. R. Hydrastin gr. x. , Leptandrin gr. iv. Aquffi giv. M. Finally, in many cases of gonorrhoea, simple iced-water injected after each passage of the urine, is very serviceable in allaying pain and irritation, and not inefficacious for the cure of the discharge. Copaiba and Gubebs. — Certain drugs which appear to possess a peculiar power in arresting inflammation of the urethral mucous membrane, are called anti-blennorrhagics. The chief of them are copaiba and cubebs. Some interesting investigations made by Ricord to determine the mode of action of these agents, are given in Eicord and Hunter on Venereal. It had already been observed m practice that copaiba and cubebs had but little curative effect upon gonorrhoea of any portion of the male or female genital I VicTOB DB M^Bic; Report to the Medical Society of London, April 30, 1860. COPAIBA AND CUBEBS. 81 organs, except the uretlira ; and it was hence suspected that they acted chiefly by their presence in the urine, and not through the general circulation; but this fact had not been demonstrated. A man with gonorrhoea chanced to enter Eicord's ward at the JT6joita'l du Midi, who had a fistulous opening communicating with the ure thra a short distance in front of the scrotum, produced by a ligature which had been applied around his penis when a child. He could at will, by separating or approximating the two edges of the fistula, either make his urine emerge from the artificial orifice, or cause it to traverse the whole extent of the urethra. Both portions of the canal were affected with gonorrhoea. Eicord administered copaiba to this patient, and directed him to pass his water entirely through the fistula. In the course of a few days, the disease was cured in the posterior portion of the canal, behind the artificial opening through which the urine had passed, while it remained unchanged in the anterior portion. He was now directed to make his water pass through the whole length of the canal, and in a few days more the anterior portion was also cured. Bj a singular coincidence, two other cases, of a similar character, soon after presented themselves in Eicord's wards, in one of which copaiba, and in the other cubebs, was given in the same manner, and the result in each was the same as in the case just described. From these experiments, Eicord concludes that copaiba and cubebs have but little influence upon gonorrhoea, unless directly applied to the diseased surface, and hence that we cannot expect decided benefit from their administration in any form of gonorrhoea, except that of the urethra in the two sexes. In gororrhoea of the vagina or vulva, or in balanitis, they are comparatively useless. The presence of these drugs in the urine is still further evinced by the odor which they impart to this fluid, and which is often suffi- cient to pervade the bedchamber occupied by the patient. ♦ It must not, however, be inferred that copaiba and cubebs have' no effect except by way of the kidneys. They are often used with benefit in other diseases than those of the urinary organs, and cannot therefore be entirely destitute of action through the general circulation. Moreover, they sometimes act as revulsives by pro- ducing copious evacuations from the bowels, and the urethral dis- charge is diminished as after the administration of a purge ;. their chief action, however, is in the manner described, by their pmesence in the urine. Such being the case, it might naturally be supposed that an emul- sion of copaiba injected into the urethra would have tha same effect^ 6 82 URETHRAL GONOERHCBA IN THE MALE. and that thus the internal administration of so nauseous a drug might be avoided. The experiment has been tried in numerous instances, but the result has always been unsatisfactory. As stated by Eicord, both copaiba and cubebs, in passing through the diges- tive organs or kidneys, undergo some modification of an unknown character, upon which their curative power depends, andwhibh cjannot be imitated by art. Dr. Hardy, of Paris, is said to have effected a cure in several cases ot vaginal gonorrhoea by giving the patients copaiba, and directing them to inject their urine into the vagina after each act of micturition. This course, however, is more interesting as an experiment than worthy of. imitation in practice. M. Eoquette, of Nantes, states that he has cured two patients who happened to be rooming together, by giving copaiba to one of them and directing the other to inject his friend's urine.' Testimony on this point, however, is not uniform. In a recent number of the Gaz. Med. de Lyon,' Diday says : " We seize the present occasion to confess, that injections, and even the retention within the urethra, of urine containing copaiba — a mode of treatment proposed by our- selves in 1843 — has not had in our hands the same success as reported by other authors, or as theoretical considerations would lead us to expect." It was formerly supposed that copaiba could be used with safety only in gleet, and even then in very small doses, and that it was inadmissible in gonorrhoea, especially in the acute stage, having a tendency, as was thought, to excite inflammation of the neck of the bladder and swelled testicle. In the latter part of the last- century, however, it was discovered that the natives of South America were in the habit of administering copaiba in large doses in all stages of g^onorrhoea, and this, too, with very great success. This led to a bolder method of administering it, and it was soon ascertained that •its curative effect is much greater in the acute than in the chronic form ©f urethritis, and that it is rarely> if ever, productive of those eompKeations which were once attributed to it.' In short, it would appear thaA copaiba can be administered with safety and to much greater advantage in the acute stage of gonorrhoea, or at an early period of the stage of decline than afterward, and the same is true ■of cubebs. :Still, when a case of this disease presents itself with ' Acoidenta DSterminfis par le Copahu. L'Union Mi5d., Dec 19, 1854. 2 For June 16, 1863. s For an interesting iistory of the remarkable change in medical opinion with regard to the administration of copaiba, see Tkocsseau, Traitfi de Th^rapeuliqne, ■yol. ii. :p. 592. COPAIBA AND CUBEB3. 83 t marked inflammatory symptomsj it is usual to wait for a day or two until ttese have been somewhat subdued by the means already mentioned before commencing with copaiba or cubebs, and I do not think that any time is thus lost ; and, in all cases, the effect of the remedy is promoted by the previous exhibition of a cathartic. The diuretics and alkalies, spoken of in connection with the . acuto stage, may be combined with these drugs, as in some of the formulas to be mentioned presently, or they may be given separately. The dose of copaiba is from twenty minims to one or even two drachms, repeated three times a day. It may be given in its pure form upon coffee, wine, or milk, but it is so disagreeable to the palate, and so likely to excite nausea, eructations, and even vomit- ing, that few persons can thus tolerate it. To render it more accept- able to the taste and stomach, it is generally given in combination ; and other ingredients are often added for the purpose of assisting its action upon the urethra. The "Lafayette mixture" in common use may be made much more acceptable to the palate by the addition of extract of liquorice, as follows : — R'. Copaibse |j. Liquoris potassse gij. Ext. glycyrrhizse ^ss. Spiritus setheria nitrici 5J. Syrupi aoacise ,^vj. Olei gaultheriae gtt. xvj. Mix the copaiba and the liquor potassse, and the extract of liquorice and s«veet epirits of nitre first separately, and then add the other ingredients. Dose. — A tablespoonful after each meal. The following are also useful formulae — R. Olei copaibse, " cubebse, aa ^j. Aluminis gij. Sacchari albi giv. Mucilaginis giij. Aquae |ij. M. Dose. — A teaspoonful three times a day. R. Copaibse, Liquoris potassse, aiJ Jjiij. Mucilaginis acacise gj. Aquse menthse viridis q. s. ad ^vj. M. (Milton.) Dose. — One ounce three times a day. R. Copaibse gx. Tincturse cantharidis, Tincturse ferri chloridi, aa •gij. M. Pose. From half a teaspoonful to a teaspoonful. 84 UEETHBAL GONOKRHCEA IX THE MALE. ^.^ Syrupi acaoise §v. Vini opii |j. Olei juniperi, Olei cubebae, aa Sij- Copaibje 3iij. Spiritus gaultheriae ^j. M. Dose.— A teaspoonful three to four times a day. (Dr. Hollywood, of Detroit.) But in wliatever "way combined, many stomachs will not tolerate copaiba in a liquid form ; hence I commonly prescribe the solidified mass, formed by the addition of magnesia, and known in the U. S. I)i